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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/principlesofsurg1901senn 


PRINCIPLES  OF  SURGERY 


N.  SENN,  M.D.,  Ph.D.,  LL.D. 

Professor  of  Surgery  in  Rush  Medical  College  in  Affiliation  with  the  University  of  Chicago  ;    Professoriai. 
Lecturer  on  Military  Surgery  in  the  University  of  Chicago  ;  Attending  Surgeon  to  the  Presbyterian 
Hospital  ;    Surgeon-in-Chief  to  St.  Joseph's  Hospital  ;   Surgeon-General  of  Illinois  ;   Late 
Lieutenant-Colonel  of  United  States  Volunteers  and  Chief  of  the  Operating- 
staff  WITH  the  Army  in  the  Field  during  the  Spanish-American  "War. 


THIRD  EDITION.     THOROUGHLY  REVISED 


(UltD  230  (Uooa-engravinds,  l^alf-tones,  and  Clolored  Illustrations 


PHILADELPHIA   AND   CHICAGO 

F.  A.  DAVIS    COMPANY,  PUBLISHERS 

1901 


COPYRIGHT,  1890, 

BY 

F.  A.  DAVIS. 
COPYRIGHT,  1895, 

BY 

THE  F.  A.  DAVIS  COMPANY. 
COPYRIGHT,  1901, 

BY 

F.  A.  DAVIS  COMPANY. 

[Registered  at  Stationers'  Hall,  London,  Eng.] 


Philadelphia,  Pa.,  U.  S.  A.: 

The  Medical  Bulletin  Printing-house, 

1916  Cherry  Street. 


PEEFACE  TO  FIEST  EDITION. 


A  MODERN  work  on  the  principles  of  surgery  in  the  English  lan- 
guage has  become  a  generally  and  well-recognized  necessity.  The  recent 
great  discoveries  relating  to  the  etiology  and  pathology  of  surgical  dis- 
eases have  made  the  text-books  of  only  a  few  years  ago  old  and  almost 
worthless.  The  many  treatises  on  surgery,  by  American  and  English 
authors,  which  have  made  their  appearance  in  rapid  succession  during 
the  last  ten  years  or  more,  are  replete  with  valuable  practical  informa- 
tion, but  most  of  them  are  defective  in  those  parts  relating  to  the 
matter  treating  of  the  fundamental  principles  of  the  art  and  science 
of  surgery. 

It  has  been  my  aim  to  write  a  book  for  the  student  and  general 
practitioner  which  should,  at  least  in  part,  fill  this  gap  in  surgical  litera- 
ture, and  which  should  serve  the  purpose  of  a  systematic  treatise  on  the 
causation,  pathology,  diagnosis,  prognosis,  and  treatment  of  the  injuries 
and  affections  which  the  surgeon  is  most  frequently  called  upon  to  treat. 
The  successful  study  and  practice  of  any  branch  of  the  healing  art  re- 
quire a  thorough  knowledge  of  the  principles  upon  which  it  is  based. 
The  student  who  has  mastered  the  principles  of  surgery  will  have  no 
difficulty  in  applying  his  knowledge  in  practice,  while  the  one  who  has 
burdened  his  memory  with  numerous  details  to  meet  special  indications 
is  always  at  a  loss  in  making  prompt  and  judicious  use  of  his  thera- 
peutic resources  when  confronted  by  rare  lesions  or  unexpected  emer- 
gencies. 

In  writing  this  book  it  has  been  my  intention  to  keep  in  constant 
view  the  difference  between  the  cellular  processes,  as  we  observe  them 
in  regeneration  and  inflammation,  and  to  connect  the  modern  science 
of  bacteriology  more  intimately  with  the  etiology  and  pathology  of  sur- 
gical affections  than  has  heretofore  been  done  by  most  authors  who  have 
written  on  the  same  subjects.  In  showing  the  direct  etiological  rela- 
tionship which  exists  between  certain  pathogenic  microorganisms  and 
definite  pathological  processes,  I  have  frequently  made  liberal  use  of 
the  experimental  and  clinical  material  contained  in  my  work  on  "Sur- 
gical Bacteriology."  When  the  subject  of  tumors  was  reached  it  was 
found  that  the  manuscript  had  become  so  voluminous  that  it  was  deemed 
advisable  to  publish  the  volume  without  this  part  of  the  intended  scope 
of  the  work, — an  arrangement  to  which  the  publisher  kindly  gave  his 
consent.     It  is  the  author's  intention  to  make  good  this  defect  by  the 

(iii)     . 


IV  PKEFACE. 

preperation,  in  the  near  future^,  of  a  special  work  on  "The  Pathology 
and  Surgical  Treatment  of  Tumors/^ 

With  few  exceptions  the  sources  from  which  my  information  was 
taken  are  not  given,  as  a  copious  bibliography  would  have  required 
considerable  valuable  space.  At  the  same  time  the  author  hopes  that 
he  has  presented  the  views  and  opinions  of  the  authorities  quoted  with 
sufficient  clearness  and  thoroughness  to  render  a  resort  to  the  original 
articles,  in  most  instances,  unnecessary.  Among  the  text-books  which 
I  have  consulted  I  desire  to  mention  the  following:  Histology:  Klein, 
Schafer,  Heitzmann,  and  Satterthwaite.  Pathology:  Klebs,  Hamilton, 
Birch-Hirschfeld,  Paget,  Virchow,  Coates,  Lebert,  Rindfleisch,  Delafield, 
and  Prudden.  The  Principles  of  Surgery:  Konig,  Hueter-Lossen,  Lan- 
derer,  Billroth- Winiwarter,  and  Van  Buren.  Bacteriology:  Flligge, 
Baumgarten,  and  Cruikshank.  The  illustrations  were  selected  from 
modern  text-books  not  readily  accessible  to  the  average  student. 

A  prolonged  absence  from  home  made  it  impossible  for  the  author 
to  attend  the  proof-reading,  and  he  asks  the  indulgence  of  the  reader 
for  any  imperfections  which  may  appear  in  the  book  from  any  sources 
for  which  he  cannot  be  held  personally  responsible. 

Should  this  volume  become  the  means  of  lightening  and  facilitating 
the  student's  work  in  acquiring  a  thorough  knowledge  of  the  funda- 
mental principles  of  surgery,  and  of  serving  as  a  useful  source  of  in- 
formation for  the  busy  general  practitioner,  the  author  will  feel  abun- 
dantly rewarded  for  the  many  sleepless  nights  which  were  required  in 
its  preparation. 

IST.  Senn. 
Milwaukee,  October,  1890. 


PKEFACE  TO  THIKD  EDITION. 


The  text  of  this  edition  has  heen  thoroughly  revised  and  many 
additions  made,  among  them  two  new  chapters,  one  on  "Degeneration" 
and  the  other  on  "Blastomycetic  Dermatitis":  snhjects  which  should 
he  included  in  a  text-hook  on  the  "Principles  of  Surgery."  Many  new 
illustrations  have  heen  added,  most  of  them  original.  The  author  be- 
speaks for  this  the  same  favorable  consideration  as  has  been  so  freely 

showered  upon  the  first  two  editions. 

N.  Senn. 


Chicago,  1901. 


(^) 


TABLE  OF  CONTENTS. 

PAGE 

Preface  to  First  Edition iii 

Preface  to  Third  Edition v 

Table  op  Contents :  vii 

List  of  Illustrations -si 

CHAPTEE  I. 
Eegeneration    1 

CHAPTER  11. 
Eegeneration  of  Different  Tissues 31 

CHAPTER  III. 
Degeneration   81 

CHAPTEE  IV. 
Inflammation 91 

CHAPTEE  V. 
Inflammation  (continued) 120 

CHAPTEE  VI. 
Pathogenic  Bacteria 157 

CHAPTEE  VII. 
Necrosis 187 

CHAPTEE  VIII. 
Necrosis  (continued) 205 

CHAPTEE  IX. 
Suppuration    220 

(vii) 


VIU  TABLE    OF    CONTENTS. 

CHAPTEE  X. 

SUPPUEATION"  (continued) 244 

CHAPTER  XL 
Ulceeation  and  Fistula 369 

CHAPTER  XII. 

SuppuKATivE  Osteomyelitis 274 

CHAPTER  XIII. 

SuppuEATioN  IN  Laege  Cavities;  Abscess  of  Inteenal  Organs.  .   309 

CHAPTER  XIV. 
Septicemia    354 

CHAPTER  XV. 
Pyemia 383 

CHAPTER  XVI. 
Eeysipelas 411 

CHAPTER  XVII. 
Tetanus    436 

CHAPTER  XVIII. 
Hydeophobia 459 

CHAPTER  XIX. 
Suegical  Tubeeculosis 475 

CHAPTER  XX. 
Clinical  Foems  of  Suegical  Tubeeculosis 506 

CHAPTER  XXI. 
Tubeeculosis  of  Lymphatic  Glands  and  Peeitoneum 529 

CHAPTER  XXII. 
Tubeeculosis  of  Bones  and  Joints 550 

CHAPTER  XXIII. 
Tubeeculosis  of  Tendon-sheaths,  etc 591 


TABLE    OF    CONTENTS.  IX 

CHAPTEE  XXIV.  p^^^ 

Actinomycosis  Hominis G19 

CHAPTEE  XXV. 
Blastomtcetic  Dermatitis 645 

CHAPTEE  XXVI. 
Anthrax 659 

CHAPTEE  XXVII. 
Glanders    679 

Index (!93 


LIST  OF  ILLUSTKATIONS. 


FIG.  PAGE 

1.  A  wound  twenty-six  hours  old.     (Thiersch) 4 

2.  A  wound  twenty-six  hours  old.     (Thiersch) 5 

3.  Quiescent  nucleus.     (Flemming) 8 

4.  Living  cell  of  salamander.     (Flemming) i 8 

5.  Endothelial  cells.      (Flemming) 9 

6.  Epithelial  cell  of  salamander.     (Flemming) 10 

7.  Epithelial  cell  of  salamander.     (Flemming) 10 

8.  Epithelial  cell  of  salamander.     (Flemming) 11 

9.  Cell-division.     (McKendrick)   13 

10.  Granulating  wound.      (Billroth-Winiwarter) 14 

11.  Granulation-tissue  from  wound.     (Hamilton) 15 

12.  Superficial  capillaries  of  a  wound  beginning  to  granulate.     (Hamilton) 17 

13.  Formation  of  new  blood-vessels  by  budding.     (Arnold) 18 

14.  Development  of  blood-corpuscles  in  connective-tissue  cells,  and  transformation  of  the 

latter  into  capillary  blood-vessels.    (Fliigge) 19 

15.  Granulating  wound  undergoing  cicatrization.     (Landerer) 20 

16.  Embryonal     connective-tissue     cell     undergoing     transformation     into     mature     state. 

(Ziegler)    ' 21 

17.  Wandering  epithelial  cells  from  frog.     (Klebs) 22 

18.  Corneal  corpuscles  in  a  state  of  proliferation.     (Senftleben) 33 

19.  Wounds  of  cornea.     (Von  Wyss) 34 

20.  Healing  of  experimental  fracture  of  the  tibia  of  a  rabbit.     (Colored) 35 

21.  Rhinoplasty  and  transplantation  of  large  skin-grafts.     (Thiersch) 40 

22.  Microscopical  appearances  of  the  interior  of  artery  of  dog 43 

23.  Microscopical  appearances  of  the  interior  of  vein  of  dog 44 

24.  Femoral  artery  of  dog  fifty  days  after  double  ligation  with  silk.     (Natural  size) 45 

25.  Collateral  circulation  eight  months  after  ligation  of  the  aorta  in  a  dog.     (Luigi  Porta) ...  46 

26.  Muscular  fibres  near  a  wound  in  a  state  of  proliferation.     (O.  Weber) 49 

27.  Muscle-suture    50 

28.  Tenorrhaphy.     (Esmarch)    , 51 

29.  Tendoplasty.     (Esmarch)    51 

30.  Secondary  suturing  of  extensor  tendons  of  fingers  by  the  suture  d  distance 52 

31.  Tendon  elongations   53 

32.  Section  through  callus.     (Bajardi) 55 

33.  Transverse  section  through  callus.     (Maas) 56 

34.  Osteoclasts  absorbing  bone 58 

35.  Old  method  of  bone-suture 60 

36.  Improved   bone-suture    60 

37.  Wire  drawn  through  the  perforation 60 

38.  Wire  cut  in  the  centre  and  each  half  twisted  separately 60 

39.  Senn's  hollow  intraosseous  splint 61 

40.  Circular  bone  ferrule  for  humerus  or  femur  made  of  an  ox-femur 61 

41.  Triangular  bone  ferrule  for  tibia  made  of  an  ox-tibia 61 

42.  Wide  perforated  bone  ferrule ■ 61 

43.  Oblique  fracture  of  femur  united  by  bone  ferrule 62 

44.  Transverse  fracture  of  humerus  immobilized  by  a  wide  perforated  bone  ferrule 62 

45.  Senn's  splint  apparatus  applied 63 

46.  Senn's  splint  apparatus  for  treating  fracture  of  the  neck  of  femur 64 

47.  Wound  of  kidney.     (Tillmanns) 66 

48.  Healing  of  wound  of  liver.     (Tillmanns) 67 

49.  Tubular  suture  of  Van  Lair  with  decalcified-bone  tube 71 

50.  Nerve-fibre  in  a  state  of  regeneration.     (Gluck) 72 

51.  Longitudinal  section  through  nerve.     (Gluck) 73 

52.  Nerve-suture,  showing  application  of  direct  and  paraneural  sutures 75 

53.  Neuroplasty.     (Letievant)    78 

54.  Cross-sutures.      (Tillmanns)    78 

55.  Ischasmic  paralysis  of  muscles  of  leg 82 

(Xi) 


Xll  LIST    OP   ILLUSTRATIONS. 

FIG.  PAGE 

56.  Patty  degeneration  of  the  heart-muscle 84 

57.  Amyloid  degeneration  of  the  kidney.     (Colored) 89 

58.  Capillary  vessels  of  the  frog's  mesentery.     (Klein) 93 

59.  Leucocyte,  showing  reticulum  of  protoplasmic  strings.     (Klein) 94 

60.  Change  of  forms  of  a  moving  leucocyte  by  amoeboid  movements.     (Klein) 95 

61.  Amoeboid  movements  of  red  blood-corpuscles.     (Leonard) 97 

62.  Third  corpuscle.     (Eberth  and  Schimmelbusch) 98 

63.  Normal  circulation  in  frog's  web.     (Landerer) 104 

64.  Capillaries  of  frog's  web  in  a  state  of  hyperemia  soon  after  application  of  irritant. 

(Landerer)    105 

65.  Plasma-cells  in  acute  interstitial  nephritis.     (Low  power.     Colored) 106 

66.  Three  plasma-cells  in  acute  interstitial  nephritis.    (High  power.    Colored) 108 

67.  Leucocyte  passing  through  capillary  wall.     (Landerer) 113 

68.  Inflammation  of  frog's  web  at  stage  where  capillary  stream  is  imbedded  by  commencing 

emigration.     (Landerer)    115 

69.  Germinating   endothelium.      (Hamilton) 124 

70.  Omentum  of  young  dog,  experimentally  inflamed.     (Hamilton) 125 

71.  Acute   pleurisy.      (Hamilton) 126 

72.  Artificial   keratitis.      (Hamilton) 133 

73.  Phagocytosis.     Struggle  between  anthrax  bacillus  and  leucocyte 136 

74.  Hueter's  inf usor  147 

75.  Cold  coil.     (Esmarch) 151 

76.  Cold  coil  for  the  head.     (Letter) .' 152 

77.  Different  forms  of  bacteria.     (Baumgarten) 158 

78.  Zoogtea   159 

79.  Endogenous  spore-production  in  bacillus  anthracis  cultivated  upon  meat-infusion  pep- 

tone-gelatin.     (Baumgarten)    160 

80.  Spore  of  bacillus  of  anthrax.     (De  Bary) 161 

81.  Gelatin  cultures  following  surface  inoculation.     (Fliigge) 163 

82.  Cultures  in  gelatin  growing  in  the  track  made  by  the  needle.     (Fliigge) 164 

83.  Experimentally-produced  growth  of  streptococci  in  centre  of  cornea  of  rabbit.     (Baum- 

garten)      191 

84.  Dry  gangrene  of  foot.     (Lebert.     Colored) 209 

85.  Vertical  section  through  a  subcutaneous  abscess.     (Baumgarten.     Colored) 225 

86.  Microscopical  pictures  of  staphylococcus.     (Rosenbach) 231 

87.  Common  forms  of  pus-microbes.     (Colored) 233 

88.  Micrococcus  pyogenes  tenuis.     (Rosenbach) 234 

89.  Microscopical  picture  of  streptococcus  pyogenes.     (Rosenbach) 234 

90.  Bacillus  pyogenes  foetidus.     (Fliigge) 235 

91.  Bacillus  pyocyaneus.     (Fliigge) 235 

92.  Bacillus  pyocyaneus    236 

93.  Gonococcus.     (Bumm)    236 

94.  Gonorrhoea!  pus   237 

95.  Gonorrhoeal  conjunctivitis.     (Bumm.     Colored) 238 

96.  Bacillus  coli  communis 238 

97.  White  corpuscles  and  pus-corpuscles.     (Koch) 239 

98.  Fragmentation  of  nucleus  in  leucocytes  undergoing  transformation  into  pus-corpuscles. 

(Landerer)    241 

99.  Pus  with  staphylococcus.     (Fliigge) 242 

100.  Pus  with  streptococcus.     (Fliigge) 242 

101.  Pus-corpuscles.     (Billroth-Winiwarter)    242 

102.  Infiltration   of   connective  tissue  of   cutis,   with   beginning  suppuration   in   the   centre. 

(Billroth-Winiwarter)   249 

103.  Vessels  (artificially  injected)  from  walls  of  an  abscess  artificially  produced  in  the  tongue 

of  a  dog.     (Billroth-Winiwarter) 250 

104.  Irrigating  apparatus   258 

105.  Osteomyelitis  of  the  tibia 282 

106.  Osteomyelitis  of  the  tibia 284 

107.  Osteomyelitis  of  the  radius.     (Sciagraph) 286 

108.  Necrosis  of  humerus.     (Lebert) 288 

109.  Sequestra  following  acute  diffuse  suppurative  osteomyelitis 289 

110.  Hollow,  padded,  posterior  splint.     (Esmarch) 290 


LIST    OF    ILLUSTRATIONS.  Xlll 

FIG.  PAGE 

111.  Board  splint  for  upper  extremity.     (Bsmarch) 290 

112.  Wire  splint.     (Esmarch) 291 

113.  Interrupted  plaster-of-Paris  splint 292 

114.  Incision  for  necrotomy  of  the  tibia 299 

115.  Bone-cavity   after   removal  of  sequestrum   and  granulations   in   necrosis   of  the  tibia. 

(Esmarch)  301 

116.  Inversion  of  soft  tissues  on  each  side  into  the  bone-cavity.     (Neuber) 302 

117.  Healing  of  bone-cavity.     (Neuber) 302 

118.  Osteoplastic  necrotomy.     (Bier) 304 

119.  Shulten's  method  of  necrotomy 305 

120.  Central  syphilitic  osteomyelitis  of  the  femur.     (Sciagraph) 306 

121.  Cortical  syphilitic  osteomyelitis  of  the  femur.     (Billings.     Sciagraph) 306 

122.  Gumma  307 

123.  Bacillus  typhosus.     (Colored) 310 

124.  Micrococcus  gonorrhoeae.     (Colored) 311 

125.  Gonococcus.      (Bumm)    312 

126.  Motor  areas  326 

127.  Wilson's   cyrtometer    328 

128.  Wilson's  cyrtometer  applied 328 

129.  Head,  skull,  and  cerebral  fissures.     (Adapted  from  Marshall) 329 

130.  Vein  of  the  diaphragm  of  a  septicaemic  mouse.     (Koch) 356 

131.  Bacillus  of  mouse-septicaemia.     (Fliigge) 357 

132.  Glomerulus  of  a  septicsemic  rabbit.     (Koch) 358 

133.  Capillary  vessels  surrounding  the  intestinal  glands  of  a  septicffimic  rabbit.     (Koch) 359 

134.  Bacillus  of  malignant  cedema.     (Koch) 360 

135.  Spore-formation  in  bacillus  of  malignant  oedema.     (Fliigge) 360 

136.  Cultures  of  bacillus  of  malignant  oedema  in  gelatin.     (Fliigge) 361 

137.  Bacillus  saprogenes  1.     (Rosenbach) 366 

138.  Bacillus  saprogenes  2.     (Rosenbach) 366 

139.  Bacillus  saprogenes  3.     (Rosenbach) 366 

140.  Proteus  vulgaris.     (Hauser) 367 

141.  Proteus  mirabilis.     (Hauser) 368 

142.  Involution  forms  of  proteus  mirabilis.     (Hauser) 369 

143.  Vessel  from  the  cortex  of  the  kidney  of  a  pyemic  rabbit.     (Koch) 386 

144.  Suppurating  thrombus  in  vein.     (Tillmanns) 389 

145.  White  thrombus.     (Landerer) 392 

146.  Red  thrombus.     (Landerer) 393 

H7.  Laminated  thrombus  in  a  vein.     (Birch-Hirschf eld) 394 

148.  Thrombophlebitis.     (Billroth) 395 

149.  Embolus  of  branch  of  pulmonary  artery.     (Birch-Hirschfeld) 397 

150.  Pyaemic  abscess  of  lung.     (Hamilton) 398 

151.  Coagulation-necrosis  from  a  kidney  infarct.     (Birch-Hirschfeld) 399 

152.  Pyaemic  pus.     (Landerer) 403 

153.  Section  of  ear  of  rabbit  parallel  to  surface  of  cartilage.    The  morbid  process  resembled 

erysipelas.     (Koch)  412 

154.  Streptococcus  erysipelatosus.     (Baumgarten) 413 

155.  Stab  culture  of  streptococcus  of  erysipelas  in  gelatin.     (Baumgarten) 414 

156.  Section  through  skin  near  the  margin  of  the  erysipelatous  zone.     (Koch) 418 

157.  Section  of  skin  in  erysipelas.     (Cornil  and  Babes) 418 

158.  Tetanus  bacilli.     (Frankel-Pfeiffer) 437 

159.  Culture  of  bacillus  tetani  in  nutrient  gelatin.     (Kitasato) 438 

160.  A  blood-vessel  from  medulla  oblongata  in  a  case  of  hydrophobia.     (Coates) 467 

161.  From  the  salivary  gland  in  a  case  of  hydrophobia.     (Coates) 468 

162.  Tubercle  bacilli  containing  spores.     (Koch.     Colored) 478 

163.  Tubercle  bacilli  from  a  tubercle  cavity.     (Colored) 478 

164.  Giant  cell  with  one  tubercle  bacillus   (Fliigge) 480 

165.  Giant  cell.    Miliary  tuberculosis.     (Fliigge) 480 

166.  Glass-slide  preparation  from  the  tissue-juice  of  a  fresh  inoculation-tubercle.     (Baum- 

garten.    Colored) 480 

167.  From  encysted  bronchial  glands  in  miliary  tuberculosis.     (Koch.    Colored) 480 

168.  Tubercle  bacilli.     (Frankel  and  Pfeiffer.     Colored) 480 

169.  Vegetations  of  tubercle  bacilli  upon  sterilized  blood-serum.     (Baumgarten.    Colored) 482 


XIV  LIST    OF   ILLUSTEATIONS. 

FIG.  PAGE 

170.  Inoculation-tuberculosis    487 

171.  Lupous  nodule  situated  deeply  in  the  corium.     (Colored) 495 

172.  Tubercle-nodule  in  lymphatic  gland 496 

173.  Giant  cell  from  centre  of  tubercle  of  lung.     (Hamilton) 497 

174.  Tuberculosis  of  trochanteric  bursa 498 

175.  Section  from  mucous  membrane  of  pharynx,  showing  epithelioid  cells  with  a  few  small 

giant  cells.     (Birch-Hirschf eld) 499 

176.  Fully-developed  reticular  tubercle  of  lung.     (Hamilton) 500 

177.  Tuberculosis  of  trochanteric  bursa 503 

178.  Caseated  submaxillary  gland.     (Colored) 504 

179.  Membrane  lining  tubercular  abscess.     (Landerer) 512 

180.  Senn's  injection-syringe   516 

181.  Tubercular  lymphadenitis  530 

182.  S-shaped  incision  in  the  operation  for  removal  of  tubercular  glands  of  the  neck 540 

183.  Tubercular  peritonitis.    Parietal  peritoneum.     (Colored) 543 

184.  Tuberculosis  of  the  lower  epiphysis  of  the  humerus.     (Sciagraph) 550 

185.  Caries  of  fourth  metacarpal  bone.     (Sanger  Brown.     Sciagraph) 554 

186.  Tubercular  focus  near  the  epiphyseal  line  of  the  lower  end  of  the  femur 555 

187.  Tuberculosis  of  astragalus.     (Tillmanns) 557 

188.  Tubercular  sequestra.     (Landerer) 557 

189.  Tubercular  infarct  in  the  head  of  the  femur.     (Volkmann) 558 

190.  Tubercular  debris  from  caseated  nodule.     (Colored) 559 

191.  Central  tuberculosis  of  the  neck  of  the  femur.    (Volkmann) 568 

192.  Tuberculosis  of  lower  epiphysis  of  femur.     (Weber) ; 571 

193.  Tubercular  empyema  of  knee-joint 574 

194.  Tubercular  coxitis  of  right  hip-joint.     (Sciagraph) 574 

195.  Knee-joints.      (Albert)    576 

196.  Dry  tuberculosis  of  the  shoulder-joint.     (Sciagraph) 576 

197.  Pathological  subluxation  of  the  hip-joint.     (Sciagraph) 578 

198.  Hahn's  incision  for  arthrectomy  or  resection  of  knee-joint 583 

199.  Interrupted  plaster-of-Paris  splint  for  resection  of  knee-joint 585 

200.  Tubercle  bacilli  in  urine.     (Colored) 613 

201.  Tubercle  bacilli  in  urine.     (Cornil  and  Babes) 614 

202.  Ray-fungus.     (Ponfick)    620 

203.  Actinomycelial  granules.     (Hektoen) 621 

204.  Actinomycosis  of  liver.     (Colored) 622 

205.  Actinomyces  from  a  section  of  a  maxillary  tumor  of  a  cow.     (Crookshank.    Colored) 623 

206.  Actinomycelial  cluster  in  giant  cell.     (Schulze) 627 

207.  Giant  cell  with  actinomycelioid  cluster.     (Lubarsch) 627 

208.  Actinomyces.     Section  from  actinomycotic  swelling.     (Fliigge) 628 

209.  Actinomyces  from  lung  of  cow.     (Marchand) 637 

210.  Miliary  abscess  in  the  epithelium  of  the  hand.     (Hektoen) 646 

211.  Three  organisms  more  highly  magnified.     (Hektoen) 647 

212.  An  epithelial  pearl.     (Coates) 648 

213.  Vacuolated  and  solid  diffusely-stained  organisms.     (Hektoen) 649 

214.  Chains  of  the  minute  form.     (Hektoen) 650 

215.  Development  of  pigment-granules.     (Hektoen) 651 

216.  Giant  cell  showing  budding  vacuolated  organism 654 

217.  Giant  cells  containing  organisms  in  different  stages  of  development 654 

218.  Giant  cell  showing  organisms  apparently  in  sporulation-stage 655 

219.  Section  showing  epithelial  proliferation.     (Herzog) 655 

220.  Miliary  abscess  of  blastomycetic  dermatitis 656 

221.  Anthrax  bacilli.    Spore-formation  and  spore-germination.     (Koch) 660 

222.  Stab  culture  of  anthrax  bacilli  in  gelatin.     (Baumgarten) 661 

223.  Anthrax  colony  upon  gelatin.     (Fliigge) 663 

224.  Intestinal  villus  of  anthracic  rabbit.     (Koch) 664 

225.  Bacillus  anthracis.     (Crookshank.     Colored) 665 

226.  Anthrax.     Section  from  liver.     (Fliigge) 672 

227.  Bacilli  of  glanders  from  a  young  potato  culture.     (Baumgarten) 680 

228.  Glanderous  nodule  from  the  liver  of  a  field-mouse.     (Baumgarten) 683 

229.  Acute  glanders.     (Birch-Hirschfeld) 689 

230.  Section  of  a  glanders  nodule.     (Fliigge.    Colored) 690 


CHAPTEE  I. 

Eegeneration. 

The  student  should  first  familiarize  himself  with  the  histological  proc- 
esses as  observed  during  the  growth,  development,  and  repair  of  tissues 
preparatory  to  a  study  of  inflammation  and  the  various  destructive  processes 
attending  and  following  it,  as  in  the  complicated  process  called  inflamma- 
tion attempts  at  repair  are  always  manifested,  and  after  its  subsidence  de- 
struction always  gives  way  to  regeneration. 

Eegeneration  includes  a  multitude  of  processes  which  are  intended  to 
repair  the  normal  physiological  waste  of  the  tissues  in  the  living  body  or 
to  restore  tissues  lost  by  injury  or  disease.  In  the  human  body  normal 
regeneration  or  repair  of  tissues  is  a  physiological  process,  which  is  essential 
for  the  maintenance  of  the  anatomical  perfection  and  functional  activity  of 
the  different  tissues  and  organs.  In  a  condition  of  perfect  health,  in  the 
full-grown  body,  the  normal  waste  incident  to  the  increasing  activity  of  the 
tissues  is  balanced  by  this  reparative  process,  while  during  the  development 
of  the  body  an  excess  of  material  is  added  upon  which  depends  the  increase 
of  tissue  which  constitutes  growth.  If  cell-destruction  is  in  excess  of  cell- 
reproduction  atrophy  is  the  inevitable  result,  and  if  the  function  of  regen- 
eration is  completely  suspended  death  must  necessarily  ensue,  the  blood 
being  the  first  tissue  the  seat  of  extreme  atrophic  changes,  soon  to  be  fol- 
lowed by  similar  changes  in  all  the  tissues,  resulting  in  diminution  of  func- 
tion proportionate  to  the  degree  of  atrophy,  and,  finally,  death  from  maras- 
mus. 

Studied  from  a  surgical  aspect,  regeneration  includes  the  process  ob- 
served in  the  healing  of  wounds  produced  by  a  trauma  and  the  complete  or 
partial  restoration  of  parts  damaged  or  destroyed  by  the  action  of  chemical 
substances,  extremes  of  cold  and  heat,  and  the  various  destructive  inflam- 
matory processes  caused  by  the  presence  of  specific  pathogenic  microorgan- 
isms. Eegeneration  and  inflammation  are  distinct  conditions,  which  should 
no  longer  be  confounded  or  considered  from  the  same  etiological  and  patho- 
logical stand-point.  An  ideal  regeneration  takes  place  without  inflamma- 
tion provided  the  seat  of  injury  or  tissue-destruction  remains  aseptic;  that 
is,  free  from  pathogenic  microbes.  On  the  other  hand,  a  regenerative  proc- 
ess within  or  around  an  inflammatory  focus  can  only  be  established  in  tissues 
in  which  the  cause  which  has  produced  the  inflammation  has  not  been  suf- 
ficiently intense  to  destroy  the  protoplasm  of  the  cells.  Under  these  cir- 
cumstances the  reparative  process  is  initiated  at  a  time  when  the  cause  which 

(1) 


2  PEINOIPLES    OP    SUEGERT. 

has  given  rise  to  the  inflammation  has  ceased  to  be  active,  or  in  tissues  not 
deprived  of  their  vegetative  power  by  its  action.  In  a  circumscribed  sup- 
purative inflammation  the  cells  exposed  to  the  direct  action  of  the  pus- 
microbes  and  their  ptomaines  are  destroyed,  and  the  process  of  repair  starts 
from  the  abscess-walls  and  their  immediate  vicinity,  from  tissues  which 
have  retained  their  power  of  cell-proliferation.  Any  organ  the  seat  of  a 
tubercular  infection,  in  which  the  parasitic  cause  is  not  sufflciently  intense 
to  destroy  the  vitality  of  the  c^lls,  retains  its  normal  structure  and  function 
by  virtue  of  this  intrinsic  power  of  regeneration  of  its  cells.  All  reparative 
processes  consist  of  homologous  cell-development,  and  the  new  tissue  re- 
sembles, anatomically  and  physiologically,  the  fixed  cells  from  which  it  is 
produced.  The  legitimate  succession  of  cells  is  now  a  well-established  law 
in  pathology  as  well  as  embryology,  and,  according  to  this  tissue,  is  never 
produced  by  substitution  of  function.  According  to  this  histogenetic  law, 
each  cell-element  possesses  an  intrinsic  vegetative  power  from  the  earliest 
embryonal  development  throughout  life,  which,  in  case  of  loss  of  tissue  by 
injury  or  disease,  enables  it  to  produce  its  own  kind  and  never  any  other 
materially  different  histological  structure.  In  conformity  with  this  general 
law  of  tissue-production,  an  injury  or  defect  of  a  nerve-flbre  is  repaired  by 
proliferation  from  preexisting  cells  which  compose  this  structure,  epithelial 
cells  are  produced  only  by  epithelial  cells,  new  vessels  are  formed  from  cells 
which  exist  in  a  normal  vessel-wall,  etc.  From  this  stand-point  will  be  con- 
sidered:— 

I.    HEALING    OF   WOUNDS. 

A  wound  may  be  deflned  as  a  sudden  solution  of  continuity  of  any  of 
the  tissues  of  the  body  caused  by  the  application  of  mechanical  force.  A 
wound  is  open  or  subcutaneous  according  as  the  surface  covering  the  skin 
or  mucous  membrane  has  been  cut  or  torn  or  has  remained  intact.  Since 
the  introduction  of  the  antiseptic  treatment  of  wounds,  the  classification 
into  open  and  subcutaneous  wounds  is  no  longer  of  the  same  practical  im- 
portance, as  an  open  wound,  under  careful  antiseptic  treatment,  Is  at  once 
placed  under  the  same  favorable  conditions  for  a  satisfactory  and  rapid  heal- 
ing as  a  subcutaneous  wound.  All  wounds,  irrespective  of  the  anatomical 
structure  of  the  tissues  involved,  heal  by  the  production  of  new  material 
from  preexisting  fixed  tissue-cells.  The  fixed  tissue-cells  at  the  site  of  in- 
jury, being  endowed  from  earliest  embryonal  life  with  a  peculiar  power  of 
adaptation  to  existing  conditions  surrounding  them,  assume  active  tissue- 
proliferation,  and  the  embryonal  cells  thus  produced  constitute  the  granula- 
tion-tissue, which,  toward  the  completion  of  the  healing  process,  is  trans- 
formed into  mature  cells,  representing  the  tissue  or  tissues  which  have  un- 
dergone the  reparative  process. 


IMMEDIATE,    OE   DIEECT,    UNION. 


IMMEDIATE,    OE   DIEECT,    UNION. 


Since  the  time  of  John  Hunter  a  great  deal  has  been  said  and  written 
on  immediate,  or  direct,  union  of  wounds.  Hunter  believed  that  this  method 
of  healing  would  be  accomplished  within  a  few  hours,  and  without  the  in- 
terposition of  new  material  between  the  accurately  coaptated  surfaces.  Ma- 
cartney was  a  supporter  of  this  view,  as  will  be  seen  from  the  following: 
"The  circumstances  under  which  immediate  union  is  effected  are  the  cases 
of  incised  wounds  that  admit  of  being,  with  safety  and  propriety,  closely  and 
immediately  bound  up.  The  blood,  if  any  be  shed  on  the  surface  of  the 
wound,  is  thus  pressed  out,  and  the  divided  blood-vessels  and  nerves  are 
brought  into  perfect  contact,  and  union  may  take  place  in  a  few  hours;  and, 
as  no  intermediate  substance  exists  in  a  wound  so  healed,  no  mark  or  cicatrix 
is  left  behind."  Paget  applies  this  method  of  healing  to  large  wounds  where 
rapid  union  is  accomplished,  and  where,  on  examination,  no  interposed  tis- 
sue is  found  between  their  edges.  Such  a  case  came  under  his  own  observa- 
tion. A  patient  on  whom  he  had  performed  an  operation  for  the  removal 
of  a  carcinomatous  breast  died  from  an  attack  of  erysipelas  a  few  days  later. 
Examination  showed  that  firm  union  had  taken  place  apparently  without 
any  intermediate  material.  He  also  made  three  experiments  on  rabbits  for 
the  purpose  of  studying  this  rapid  method  of  repair.  The  hair  was  removed, 
the  skin  incised,  and  the  wound  accurately  sutured.  Three  days  later  he 
examined  the  parts,  and  found  the  wound  quite  firmly  united,  without  any 
macrosccJpical  evidences  of  inflammation.  On  microscopical  examination  he 
found  some  exudation  material  in  the  immediate  vicinity  of  the  wound. 

Among  the  more  modern  investigators,  we  find  Thiersch  still  uphold- 
ing the  possibility  of  immediate  union  by  direct  cohesion  of  similar  parts. 
He  studied  the  repair  of  wounds  in  the  tongue  of  guinea-pigs.  The  tongue 
was  incised  in  a  longitudinal  direction,  and  the  parts  were  examined  a  few 
hours  to  several  days  after  the  injury  had  been  inflicted.  Before  sections 
were  made  for  microscopical  examination  the  lingual  vessels  were  injected 
with  liquid  glue  stained  with  carmine.  In  specimens  where  the  wound  was 
only  a  few  hours  old  he  found,  at  least,  parts  of  the  wound  firmly  adherent^ 
and  on  microscopical  examination  he  satisfied  himself  that  the  connective 
tissue,  saturated  with  blood  and  plasma,  had  formed  an  immediate  and  per- 
manent union.  He  described  also  a  plasmatic  circulation  in  the  wound 
which  he  considered  of  great  importance  for  the  nutrition  of  the  tissues. 
He  believed  that  these  new  channels,  by  becoming  paved  with  the  adjacent 
connective  cells,  could  be  transformed  into  permanent  blood-vessels. 

The  same  section  examined  under  a  higher  power  furnishes  a  good 
illustration  of  the  part  taken  by  the  fixed  tissue-cell  in  the  repair  of  the 
wound. 


PEINCIPLES    OF    SURGEEY. 


Some  surgeons  still  believe  in  immediate  union  in  the  repair  of  wounds 
of  nerves,  as  many  cases  have  been  reported  where  complete  restoration  of 
function  was  claimed  to  have  been  established  within  a  few  hours  after  nerve- 
suture.  Such  observations  are  not 
free  from  criticism,  because  func- 
tional results  after  nerve-suture 
may  lead  to  wrong  conclusions,  as 
restoration  of  function  in  distal 
parts  may  be  owed  to  the  presence 
of  other  nerves  which  reach  such 
parts,  and  it  may  be  due  partly  to 
physical  conduction  of  irritation. 
The  occurrence  of  immediate  union 
was  doubted  by  O'Halleran,  a  dis- 
tinguished contemporary  of  Bell,  as 
may  be  learned  from  the  following 


Fig.  1.— A  Wound  Twenty-six  Hours  Old.  A,  coaptated  parts  apparently  united. 
Tissues  only  slightly  stained  with  coloring  material  of  blood;  few  leucocytes.  B,  B, 
spaces  between  wound-surfaces  filled  with  red  and  white  blood-corpuscles,  some  of' the 
former  well  preserved,  others  showing  various  degrees  of  disintegration;  between  them 
oedematous  connective-tissue  fibres.  O,  C  show  that  these  fibres  are  continuous  with  the 
connective  tissue  of  the  wound-surfaces.  Surface  of  wound  coaptation  imperfect-  the 
epithelial  cells  dip  down  into  the  wound.  D,  a  separated  cone  of  new  tissue.  B,  infil- 
tration of  fatty  tissue  with  blood  and  leucocytes.  Gf,  divided  muscular  fibres'  with 
escaped  pieces  which  have  partly  undergone  colloid  degeneration.  (Hartnack  obi  4 
00.  2.)     (Thiersch.)  '         '     ' 

quotation:  "I  would  ask  the  most  ignorant  tyro  in  our  profession  whether 
he  ever  saw,  or  heard  even,  of  a  wound,  thou.gh  no  more  than  one  inch  long, 
united  in  so  short  a  time,"  adding:  "These  tales  are  told  with  more  con- 
fidence than  veracity;    healing  by  inosculation,  by  the  first  intention,  by 


IMMEDIATE,    OR    DIRECT,    UNION.  O 

immediate  coalescence  without  suppuration  is  merely  chimerical  and  opposite 
to  the  rules  of  nature." 

Gussenbauer  repeated  the  experiments  of  Thiersch  and  Wywodzoff  on 
the  healing  of  wounds  in  the  tongue  of  guinea-pigs,  and  came  to  entirely 
different  conclusions.  In  wounds  eight  to  twelve  hours  old  he  found  that 
the  margins  formed  an  elliptical  space,  the  separation  being  widest  in  the 
middle.  The  divided- muscular  fibres  had  retracted,  imparting  to  the  wound 
an  uneven  surface,  which  was  covered  with  a  layer  of  reddish,  gelatinous 
material.     In  recent  wounds  the  space  is  filled  with  blood-corpuscles  which 


Fig.  2. — A,  embryonal  cells  showing  karyokinetic  figures:  B,  lymph-spaces;  C, 
striped  masses  infiltrated  with  red  blood-corpuscles  in  various  stages  of  disintegration; 
D,   blood-vessel;     F,   fat-tissue.     (Hartnack,   obj.   8,   oc.   4.)     (Thiersch.) 


are  often  much  changed  in  color,  size,  and  shape.  In  wounds  twenty-four 
to  fortjr-eight  hours  old  the  material  between  the  surfaces  of  the  wound 
presented  a  reticulated  appearance,  each  one  of  the  spaces  corresponding  to 
a  blood-vessel.  Contrary  to  Thiersch,  he  asserts  that  in  this  substance  no 
connective  tissue  can  be  found;  the  reticulated  structure  he  attributed  to 
the  presence  of  fibrin,  the  coagulum  infiltrating  at  the  same  time  the  ad- 
jacent tissues.  He  believes  that  the  parenchyma-fluid  takes  part  in  the 
formation  of  the  coagulum.  He  was  unable  to  verify,  by  his  own  observa- 
tions, the  existence  of  the  plasma-channels  described  by  Thiersch.  When 
the  wound-surfaces  were  kept  accurately  approximated  he  found  few  blood- 


b  PRINCIPLES    OF    SUEGERY. 

corpuscles,  but  the  net-work  of  fibrin  was  never  absent.  In  harelip  opera- 
tions and  incised  wounds  of  the  face  and  scalp,  if  uninterrupted  apposition 
is  maintained  for  a  day  or  two,  the  parts  are  found  so  firmly  glued  together 
that  the  belief  that  immediate  union  had  taken  place  might  still  be  main- 
tained from  a  superficial  examination,  but  a  microscopical  examination  will 
always  reveal  the  conditions  described  by  Gussenbauer,  and  the  union  is 
therefore  only  apparent,  and  not  real.  The  surfaces  of  the  wound  have  be- 
come adherent  by  the  interposition  of  an  adhesive  material.  A  certain 
amount  of  coagulation-necrosis  takes  place  in  every  wound,  and  the  mate- 
rial thus  formed  serves  as  a  cement-substance  which  temporarily  glues  the 
parts  together.  This  mechanical  union,  the  result  of  destructive  chemical 
changes  in  the  extravasated  blood,  is  the  form  of  union  which  has  been 
wrongly  interpreted  and  described  as  immediate  union.  This  primary  ad- 
hesion occurs  most  readily  in  wounds  of  dense  vascular  tissue  and  where 
approximation  and  fixation  of  the  edges  of  the  wound  are  most  thoroughly 
secured, — conditions  which  favor  the  subsequent  definitive  healing  of  the 
wound  by  the  interposition  of  new  tissue. 

UNION    BY    PRIMARY    INTENTION. 

Organic  union,  the  union  aimed  at  in  the  treatment  of  all  wounds,  is 
only  obtained  by  tissue-proliferation  from  the  fixed  cells  of  the  injured 
parts,  and  is  completed  only  after  restoration  of  the  continuity  of  the  divided 
structures,  and  the  return,  partial  or  complete,  of  the  functions  suspended 
by  the  injury  or  disease.  Eeturn  of  structure  and  function  to  an  at  least 
approximately  normal  standard  implies  a  return  of  the  interrupted  circula- 
tion by  the  formation  of  new  blood-vessels;  in  other  words,  organic  union 
cannot  be  said  to  have  taken  place  without  an  adequate  supply  of  new  blood- 
vessels in  the  new  tissue  which  form  a  capillary  collateral  net-Avork  be- 
tween the  divided  blood-vessels.  Such  a  union,  even  under  the  most  favor- 
able circumstances,  cannot  be  established  in  less  than  six  to  eight  days, 
and  its  attainment  may  require  weeks  and  months.  The  next  method  of 
repair  described  by  John  Hunter  was  union  by  adhesive  inflammation.  Ab- 
sence of  suppuration  and  rapid  union  have  always  been  considered  as  essential 
features  of  this  mode  of  healing,  and  corresponds  to  the  healing  of  wounds 
per  primam  intentionem, — an  expression  which,  for  obvious  reasons,  has  been 
retained  in  modern  literature  to  distinguish  it  from  the  method  of  healing 
per  secundem  intentionem,  where  the  reparative  process  is  often  indefinitely 
delayed  by  suppuration.  All  wounds  which  heal  without  suppuration  heal 
by  primary  union,  either  without  or  with  visible  granulation-tissue.  An 
ideal  result  is  obtained  if  the  separated  surfaces  unite  throughout  and  the 
repair  in  the  depth  of  the  wound  is  accomplished  during  the  same  time  un- 


KAKYOKINESIS.  V 

derneath  the  united  skin  or  mucous  membrane.  If  there  has  been  a  con- 
siderable loss  of  surface  tissue  and  the  superficial  portion  of  the  wound  can- 
not be  approximated,  or,  if  rapid  healing  at  the  surface  of  the  wound  fails 
to  take  place,  the  wound  heals  slowly  by  the  formation  of  a  larger  amount 
of  granulation-tissue,  and  yet,  if  suppuration  does  not  complicate  the  process, 
it  must  be  said  that  the  wound  has  healed  by  primary  union.  This  method 
of  healing  was  exceedingly  rare  before  antiseptic  surgery  was  practiced,  but 
since  that  time  it  is  of  frequent  occurrence.  All  wounds  which  heal  without 
suppuration  heal  without  inflammation.  All  inflamed  wounds  suppurate; 
the  reparative  process  is  delayed  until  the  inflammation  has  subsided.  The 
proper  modern  classification  of  wounds  in  reference  to  the  method  of  repair 
consists  in  a  distinction  between  (1)  aseptic  wounds  and  (2)  infected  wounds. 
Aseptic  wounds — that  is,  wounds  not  contaminated  with  paihog&nic  microor- 
ganisms— heal  without  inflammation.  An  aseptic  wound,  as  a  rule,  is  pain- 
less, and  does  not  present  any  of  the  other  witnesses  of  inflammation.  The 
slight  swelling  and,  perhaps,  redness  are  the  result  of  mechanical  disturb- 
ances of  the  circulation,  and  subside  with  the  formation  of  an  adequate  col- 
lateral circulation;  hence,  from  an  etiological  and  pathological  point  of 
view,  we  have  no  legitimate  right  to  apply  the  term  inflammation  to  such 
a  method  of  repair.  Koenig  makes  the  statement  that  the  product  of  tis- 
sue-proliferation in  the  healing  of  an  aseptic  wound  is  not  in  excess  of  the 
local  demand;  hence,  the  process  is  purely  one  of  regeneration,  and  not 
inflammation.  Hueter  was  one  of  the  first  who  insisted  on  limiting  the 
meaning  of  the  term  inflammation,  which  he  wished  to  have  applied  only 
to  destructive  processes  caused  by  the  action  of  specific  microbes.  In  an 
aseptic  wound  the  fixed  tissue-cells  assume  tissue-proliferation,  by  virtue  of 
their  intrinsic  vegetative  power,  within  a  few  hours  after  the  injury  has 
been  inflicted,  and  all  the  permanent  material  utilized  in  the  process  of  re- 
pair is  derived  from  this  source.  The  leucocytes  serve  a  useful  purpose  in 
the  temporary  closure  of  divided  capillary  vessels  and  in  the  formation  of 
the  temporary  cement-substance  by  which  the  surfaces  of  the  wound  are 
mechanically  glued  together,  and,  lastly,  as  food  for  the  embryonal  cells, 
l)ut  they  taJce  no  active  part  in  the  production  of  new  tissue. 

In  studying  the  process  of  healing  in  wounds  as  well  as  in  the  consid- 
eration of  regeneration  in  general,  it  is  of  the  greatest  importance  to  become 
familiar  with  the  histological  changes  which  precede  and  attend  the  forma- 
tion of  new  tissue;  hence,  in  this  connection  should  be  given  a  description 
of 

KAEYOKIlSrESIS. 

Karyokinesis,  or  karyomitosis,  as  described  by  Fkmming,  is  the  in- 
direct reproduction  of  cells  as  compared  with  direct  cell-division  by  seg- 


a  PEINCIPLES    OF    SUEGEEY. 

mentation.  It  is  a  process  by  which  the  net-work  of  chromatin  threads 
within  the  nucleus  undergoes  great  development,  and  is  subject  to  certain 
transformations  of  form,  which  are  instrumental  in  effecting  division  of 
nucleus  and  cell.  The  term  karyokinesis  was  first  used  by  Schleicher,  and 
the  first  accurate  description  of  the  process,  as  seen  in  the  cells  of  a  number 
of  animals,  simple  in  form  and  structure,  was  given  by  Biitschli  in  1876. 
The  modern  definition  of  a  cell  is  much  more  complicated  than  that  given 
by  Schleiden  and  Schwann,  as  recent  researches  have  shown  that  it  is  not 
such  a  simple  structure  as  it  was  formerly  believed  to  be.  When  we  speak 
of  a  cell  now  we  mean  a  mass  of  circumscribed  living  substance,  with  or  with- 
out an  envelope,  which  contains  as  an  essential  element  in  its  interior  a 
nucleus,  with  the  property  of  forming  new  compounds  out  of  substances 
taken  into  it,  and  is  capable  of  reproduction  by  division.  Both  the  nucleus 
and  cell  are  composed  of  threads  and  intermediate  substance.     The  cell- 


Fig.  3. 


Fig.  4. 


Fig.  3. — Quiescent  Nucleus.     Epithelial  Cell  of  Salamander  Entering  upon  the 
"Glomerular"  Phase.     (Flemming.) 
Fig.  4.— Living  Cell  of  Salamander.    A,  granules  aggregated  round  a  pole  of  the  ceU; 
B,  coils  of  "glomerular"  net- work;    C,  cell-body.     (Flemming.) 

body  consists  of  threads  somewhat  irregularly  distributed,  seldom  forming 
a  net-work,  imbedded  in  a  homogeneous  substance.  The  nuclear  threads 
stain  with  hsematoxylin  and  safranin,  and  hence  are  called  chromatin 
threads,  which  are  arranged  in  a  net-like  figure,  the  meshes  of  which  are 
filled  with  a  substance  which  cannot  be  stained,  and  hence  is  named  by 
Flemming  achromatin.  The  nucleus  is  surrounded  by  a  membrane  com- 
posed of  two  layers;  the  inner  can  be  stained,  but  not  the  outer.  The 
nucleoli,  usually  multiple,  are  made  up  of  a  substance  more  refractile  than 
the  structures  described  in  the  nucleus.  They  are  round  and  smooth,  and 
either  suspended  in  the  net-work  or  between  the  threads.  The  nucleus  in 
a  cell  that  is  not  in  a  condition  of  functional  activity  is  said  to  be  in  a  quies- 
cent or  resting  state. 

At  this  time  the  chromatin  threads  become  transformed  into  a  sort  of 
skein,  formed  apparently  of  one  long,  convoluted  thread;    the  inner  layer 


KAKYOKINESIS.  9 

of  the  nuclear  membrarie  and  nucleoli  disappear,  or  are  incorporated  into 
the  achromatin  substance  of  the  nucleus.  The  development  of  the  net-work 
of  the  chromatin  substance  in  the  nucleus  undergoes  five  phases  until  com- 
plete division  of  the  nucleus  and  cell  has  been  effected. 

Phase  I.  The  first  change  indicative  of  beginning  karyokinesis,  accord- 
ing to  Flemming,  is  the  formation  within  the  cell-protoplasm  of  two  poles 
opposite  to  each  other  and  near  the  nucleus. 

The  next  change  noticed  is  that  in  the  nucleus:  the  chromatin  threads 
become  plainer,  thicker,  and  more  convoluted.  This  increase  of  chromatin 
substance  is  the  result  of  longitudinal  splitting  of  its  threads.  The  achro- 
matin layer  of  the  nuclear  envelope  increases  in  thickness,  while  the  inner 
layer  has  become  a  part  of  the  chromatin  net-work. 

Phase  II.  Durina:  this  stage  the  chromatin  threads  are  drawn  out  into 


Fig.  5.— Endothelial  Cells;  Abdomen  of  Salamander.  1.  Surface  view  of  nuclear 
net-work;  A,  cell-body;  B,  threads  of  net- work;  0,  one  of  the  poles  with  the  achro- 
matin threads  radiating  from  it.  2.  Equatorial  view  of  a  corresponding  cell;  A,  one  of 
the  poles;  B,  the  nuclear  net-work  seen  on  edge;  C,  the  achromatin  threads  forming 
a  spindle  between  the  poles.     {Flemming.) 

loops  with  long  limbs.  This  arrangement  imparts  to  the  looped  net-work 
the  figure  of  an  aster,  or  star. 

In  the  middle  of  the  star  is  a  clear  space,  which  does  not  stain  and  is 
occupied  by  achromatin  substance.  In  animal  cells  the  greater  portion  of 
the  space  within  the  nuclear  membrane  is  filled  with  chromatin  threads, 
while  in  vegetable  cells  the  achromatin  substance  predominates.  The 
nuclear  spindle  in  the  centre  of  the  achromatin  substance  (Fig.  4,  C),  ac- 
cording to  Strassburger  and  Biitschli,  consists  of  fine,  colorless  fibres,  which 
do  not  stain  at  all,  or  only  slightly,  by  using  special  nucleus-staining  re- 
agents, and  on  this  account  the  achromatin  threads  probably  contain  no 
nuclein. 

Phase  III.  The  star-shaped  mass  of  nuclear  threads  divides  into  two 
equal  portions,  with  the  angles  of  the  loops  to  the  poles,  and  theiT  limbs 
partly  obliquely,  partly  perpendicularly  to  the  equator  of  the  nucleus. 


10 


PEINCIPLES    OF    SURGERY. 


The  equatorial  disk  is  formed  in  this  manner,  and  indicates  the  com- 
pletion of  this  phase. 

Phase  IV.  This  phase  begins  with  a  separation  of  the  threads  at  the 
equator,  and  ends  with  concentration  of  the  threads  in  each  polar  segment 
of  the  cell. 

As  the  number  of  loops  in  each  segment  is  the  same  as  in  the  old  nucleus, 
it  may  be  conjectured  that  the  halves  of  each  thread  separate  into  the  two 
daughter-stars. 

Phase  V.  The  threads  in  the  daughter-nucleus  form  a  wreath,  after 
which  they  contract  more  and  more  until  the  undivided  convolutions  can 
hardly  be  recognized. 

A  nuclear  membrane  again  appears,  after  which  the  net-work  returns 
to  its  quiescent  state. 


Fig.  7. 

Fig.  6. — Epithelial  Cell  of  Salamander.     A,  pole  and  achromatin  threads;  B,  cell-body.; 
C,  disk-like  arrangement  of  chromatin  threads  at  equator  of  nucleus.     (Flemming.) 
Fig.  7.— Epithelial  Cell  of  Salamander.    A,  A',  chromatin  threads  of  daughter-stars; 
B,  achromatin  threads  and  pole.     (Flemming.) 

There  is  a  strong  tendency  at  the  present  time  to  refer  all  karyokinetic 
changes  to  the  agency  of  the  nucleus,  and  to  ascribe  to  the  protoplasm  of 
the  cell  the  passive  role  of  a  nutritive  substance.  In  the  impregnated  ovum 
the  influence  of  nuclear  changes  has  been  described,  but  at  the  same  time 
it  was  shown  that  the  protoplasm  of  the  cell  is  capable  of  automatic  as  well 
as  responsive  action.  Pfiliger  asserted  that  gravitation  is  the  sole  guiding 
agency  in  the  process  of  cleavage  of  protoplasm.  According  to  Born,  Herturg, 
Weismann,  and  Kolliker,  the  protoplasm  alone  is  isotropic,  but  Whitman 
thinks  that  this  is  far  from  the  truth.  Others,  like  Pflueger,  believe  that 
the  protoplasm  contains  physiological  molecules  from  which  organs  are  de- 
veloped. Polarity  of  cell-protoplasm  and  in  nucleus  exists  independently, 
and  is  not  reciprocal.  Contractions  in  unfertilized  ova  have  been  observed. 
M.  Nussbaum  was  first  to  prove  that  enucleated  fragments  of  an  infusorium 
are  incapable  of  reproduction,  while  parts  of  an  infusorium  containing  a 


KAEYOKINBSIS. 


11 


nucleus  possessed  this  power.  This  would  tend  to  establish  the  fact  that 
the  nucleus  is  indispensable  to  the  preservation  of  the  vegetative  energy  of 
the  cell.  On  the  other  hand,  Gru.ber,  in  one  of  his  experiments,  divided  a 
stentor  before  fission  had  taken  place  in  such  a  manner  that  the  sections 
contained  no  nuclear  substance,  and  yet  the  next  day  each  one  of  these  parts 
represented  a  complete  stentor.  Against  the  conclusions  drawn  from  this 
experiment  it  might  be  urged  that  some  of  the  nuclear  chromatin  threads 
might  have  found  their  way  into  the  cell-protoplasm,  and  that  from  them 
the  process  of  reproduction  started.  Nussbaum  regards  a  combination  of 
nuclear  structure  and  cell-protoplasm  as  essential  for  cell-production.     Ac- 


Fig.  8.— Epithelial  Cell  of  Salamander.    A,  A',  daughter-glomeruli;    B,  achromatin 
threads  still  uniting  the  two  daughter-cells.     {Flemming.) 

cording  to  Flemming,  the  cell-body  begins  to  divide  toward  the  end  of  the 
fourth  phase  of  karyokinesis.  Cell-division  commences  with  a  constriction 
at  the  equator,  which  becomes  deeper  and  deeper  as  the  daughter-cells  as- 
sume cell  form,  until  complete  segmentation  takes  place.  Toward  the  com- 
pletion of  the  separation  only  a  few  achromatin  threads  (Fig.  8,  B)  connect 
the  two.  To  Flemming  belongs  the  credit  of  having  first  discovered  karyo- 
kinetic  changes  in  cells  undergoing  division,  but  our  knowledge  of  this  sub- 
ject has  been  greatly  advanced  by  the  combined  labors  of  Strassburger, 
Arnold,  Klebs,  and  Whitman.  Arnold  studied  this  method  of  cell-division 
in  giant  cells  of  the  medulla  and  in  the  blood-corpuscles  of  leuksemic  blood. 


12  PEINCIPLES    OF    SURGEEY. 

He  preserved  the  blood-corpuscles  in  a  6-per-cent.  methyl-green  salt-solu- 
tion^ which  preserves  cells  in  a  good  condition  if  the  solution  is  kept  at  a 
proper  temperature  in  the  moist  chamber  on  the  object-glass.  If  to  this 
solution  a  25-per-cent.  solution  of  chloride  of  gold  is  added,  the  karyokinetic 
figures  are  made  clearer.  In  studying  the  process  of  karyokinesis  in  fixed 
tissue-cells  in  a  state  of  proliferation,  it  is  necessary  to  resort  to  the  fixation 
and  staining  methods  described  by  Flemming.  The  modern  observers  who 
have  studied  regeneration  of  epithelial  cells  have  come  to  the  conclusion  that 
cell-division  takes  place  almost  exclusively  by  karyokinesis.  Podwyssozki 
has  studied  this  method  of  cell-reproduction  with  special  reference  to  regen- 
eration of  liver-cells,  and  has  come  to  some  very  important  conclusions.  In 
cats  and  young  guinea-pigs  he  observed,  after  injury  of  the  liver,  extra- 
nuclear  chromatin  substance  before  he  could  detect  any  karoykinetic  figures 
in  the  nucleus.  The  chromatin  in  the  cell-body  appeared  in  two  forms: 
either  as  fine  granules  scattered  diffusely  through  the  protoplasm  of  the  cell 
or  as  lumps  of  chromatin,  and  he  designated  these  larger  masses  as  pro- 
chromatin;  but  he  also  noticed  that  the  granular  form,  at  a  later  stage, 
aggregated  and  formed  masses  which  united  with  the  nuclear  chromatin. 
Klebs  explains  the  presence  of  chromatin  in  the  cell-protoplasm  to  an  extra- 
cellular origin:  the  leucocytes.  He  believes  that  the  chromatin  contained 
in  leucocytes  is  liberated  after  fragmentation  has  taken  place  and  enters  the 
young  cells,  where  they  serve  as  food  and  become  a  part  of  the  nuclear  net- 
work. This  view  is  strengthened  by  the  statement  of  Podwyssozki  that  he 
found  numerous  leucocytes  in  the  immediate  vicinity  of  the  new  cells. 
Ziegler  and  Obolensky  produced  arsenical  intoxication  in  animals  by  ad- 
ministering the  drug  in  daily  doses  subcutaneously,  and  when  they  examined 
the  liver  they  found  well-marked  karyokinetic  figures  in  the  endothelial  cells 
of  the  intraacinous  capillaries,  the  epithelia  of  the  bile-ducts,  and,  less  fre- 
quently, in  the  secreting  cells.  Karyokinetic  figures  were  first  visible  in  the 
nuclei  of  the  capillary  endothelia,  and  were  undoubtedly  caused  by  the  direct 
action  of  the  arsenic  upon  the  cells.  These  experiments  show  that  karyo- 
kinesis will  follow  the  application  of  chemical,  as  well  as  traumatic,  irritants. 

FEAGMENTATION    OF    NUCLEUS. 

Arnold  and  Pfitzner  have  described,  in  giant  and  other  cells  under- 
going pathological  changes,  direct  fragmentary  division  of  the  nucleus,  by 
which  it  may  break  up  into  many  parts,  often  of  unequal  size,  without  con- 
temporaneous division  of  the  cell.  Arnold  and  others  have  also  described 
incomplete  fragmentation  of  the  nucleus  where  the  nuclear  masses  remain 
connected  with  each  other,  and  can  be  seen  as  lobulated  and  reticulated 
structures.     Arnold  saw  fragmentation  of  the  nucleus  in  the  cells  of  the 


GRANULATION-TISSUE.  13 

marrow  of  bone  and  in  leucocytes  undergoing  transformation  into  pus-cor- 
puscles. A  nucleus  which  undergoes  fragmentation  contains  but  little 
chromatin  substance,  and  is  therefore  incapable  of  multiplication  by  karyo- 
kinesis;  and  such  cells,  according  to  the  investigations  of  Klebs,  never  take 
an  active  part  in  the  regeneration  of  tissue. 

-DIEECT    CELL-DIVISION. 

In  1841  Martin  Barry  first  made  the  observation  that  the  division  of 
cells  was  accompanied  with  division  of  the  nucleus,  and  for  a  long  time  it 
was  believed  that  this  process  is  simply  a  segmentation  of  the  nucleus,  fol- 
lowed by  division  of  the  whole  cell.  Eemak  taught  that  direct  division  com- 
menced in  the  nucleolus,  extended  to  the  nucleus,  and  finally  resulted  in 
fission  of  the  cell-body,  each  of  the  new  cells  containing  a  daughter-nucleus. 

According  to  Pfitzner,  direct  cell-division  is  a  more  frequent  method  of 
cell-multiplication  than  the  indirect  in  young  animals  where  cell-prolifera- 
tion is  rapid.  In  the  embryo  the  nucleus  contains  but  little  chromatin,  and 
therefore  the  karyokinetic  figures  are  less  abundant. 


c  D 

Fig.  9. — A,  mature  cell;  B,  commencing  division  of  nucleus  and  contraction  of  cell- 
protoplasm  in  the  centre;  C,  complete  division  of  nucleus  and  cell;  Z),  formation  of  two 
new  cells.     (McKendrick.) 

In  most  of  the  regenerative  processes  in  mature  tissue-cells  reproduc- 
tion takes  place  by  karyokinesis,  and  only  in  exceptional  instances  by  direct 
division.  The  new  cellular  elements  present  karyokinetic  figures  in  all 
stages,  and  wherever  these  are  seen  it  is  a  positive  evidence  that  the  fixed  tissue- 
cells  are  the  seat  of  tissue-proliferation,  and  that  wounds  are  healed  and  defects 
repaired  exclusively  by  this  method  of  cell-formation. 

GEANULATION-TISSUE. 

The  new  cells  formed  by  indirect  or  direct  cell-division  in  a  wounded 
or  injured  part,  the  seat  of  regenerative  processes,  constitute  the  granula- 
tion-tissue as  long  as  they  remain  in  their  embryonal  state.  As  immediate 
union  never  takes  place  in  any  part  or  tissue  of  the  body,  we  are  forced  to 
admit  that  every  wound  heals  only  by  the  interposition  between  the  divided 
parts  of  a  greater  or  less  amount  of  granulation-tissue.  If  the  wound  remain 
aseptic,  and  the  surfaces  of  the  wound  are  kept  in  accurate  coaptation,  the 
healing  is  accomplished  in  a  short  time,  and  by  the  production  of  a  mini- 
mum amount  of  new  tissue.    A  similar  wound,  with  great  loss  of  tissue  pre- 


14 


PEINCIPLES    OF    SUKGERY. 


eluding  the  possibility  of  bringing  the  parts  in  apposition  by  mechanical 
resources,  must  necessarily  heal  by  the  production  of  a  large  quantity  of 
granulation-tissue,  the  process  of  repair  in  both  instances  being  the  same, 
the  difference  being  mainly  the  length  of  time  required  to  complete  the  heal- 
ing process  and  the  amount  of  new  material  necessary  for  this  purpose.  In 
the  first  case  the  wound  heals  without  visible  granulation-tissue;  in  the 
latter  the  defect  becomes  covered  with  granulations  before  the  wound  can 
heal.  The  macroscopical  and  microscopical  appearances  of  granulating  sur- 
faces are  nearly  identical  in  all  the  tissues.  A  bone  covered  with  granula- 
tions looks  the  same  as  a  granulating  surface  of  any  of  the  soft  tissues.    Even 


Pig.  10. — Granulating  Wound.     Capillary  Loops  Surrounded  by  Embryonal  Cells. 
X  300-400.     {Billroth-Winiwarter.) 

the  embryonal  cells  of  which  the  granulations  are  covered,  so  long  as  they 
remain  in  this  state,  furnish,  from  their  microscopical  appearances,  only  re- 
mote or  no  indications  as  to  their  histogenetic  source  and  ultimate  destina- 
tion. Differentiation  takes  place  during  their  further  development  toward 
the  completion  of  the  healing  process.  The  bulk  of  all  granulation-tissue  is 
derived  from  the  connective  tissue,  as  this  mesoblastic  structure  is  diffused 
throughout  the  entire  body,  and,  with  the  exception  of  the  nervous  system, 
is  found  in  almost  every  organ.  In  the  nervous  system  it  is  represented  by 
an  almost  similar  tissue, — the  neuroglia, — which  performs  the  same  role 
in  the  repair  of  injuries  and  defects  of  the  brain  and  spinal  cord.    A  wound 


GRANULATION-TISSUE. 


15 


or  defect  covered  with  granulations  presents  a  velvety  appearance,  each  tuft 
or  papilla  representing  a  separate  loop  or  net-work  of  new  capillary  vessels. 
The  new  capillary  vessels  are  paved  with  endothelial  cells  containing 
a  very  large  nucleus.  Sometimes  a  single  capillary  vessel  enters  a  papilla 
and  gives  off  a  number  of  branches,  which  form  a  net-work  of  convoluted 
vessels,  rendering  the  granulations  exceedingly  vascular  and  liable  to  bleed 
on  the  slightest  provocation. 

Fig.  11. — Granulation-tissue  from  Wound.  Blood-vessels  Injected.  X  400.  A,  A, 
capillary  loops  with  several  branches;  B,  ordinary  granulation-cells;  G,  fibroblasts;  D, 
stroma.     (Hamilton.) 


The  blood  in  the  tuft  is  collected  and  returned  usually  through  one 
vein.  Emigration  of  leucocytes  through  the  walls  of  the  new  capillary  ves- 
sels is  a  common  occurrence,  and,  when  they  reach  the  surface,  form  one 
of  the  elements  of  secretion  of  the  wound.  When  the  capillary  vessels  are 
imperfectly  developed,  or  when  they  are  in  a  state  of  inflammation,  the  ex- 
udation becomes  profuse  and  the  granulation-surface  becomes  covered  with 
a  membrane  consisting  of  the  products  of  coagulation-necrosis.     Wounds 


16  PRINCIPLES    OF    SURGEEY. 

presenting  such  an  appearance  have  frequently  been  mistaken  as  an  evidence 
of  diphtheritic  infection.  The  so-called  healthy  granulations  are  small, 
firm,  and  of  a  pinkish-red  color,  and  the  surface  from  which  they  spring  is 
only  moistened  with  colorless,  viscid  fluid.  Wounds  covered  with  such  gran- 
ulations heal  rapidly  and  leave  a  small,  pliable  cicatrix.  Profuse  flabby  and 
pale  granulations  indicate  a  want  of  general  vitality,  or  more  frequently  the 
presence  of  pathogenic  microbes,  which  act  injuriously  upon  the  process  of 
transition  of  embryonal  cells  into  tissue  of  a  higher  type.  Such  granulations 
are  frequently  met  with  in  wounds  after  imperfect  operations  for  tubercular 
lesions,  in  suppurating  wounds,  and  in  ulcers  of  the  lower  extremities,  where 
the  vascular  conditions  are  unfavorable  for  the  growth  and  development 
of  new  tissue.  Histologically  granulation-tissue  is  composed  of  a  delicate, 
oedematous  reticulum,  and  upon  its  fibres  can  be  seen  numerous  connective- 
tissue  corpuscles.  The  reticulum  is  intimately  connected  with  the  blood- 
vessels, and  in  its  meshes  are  contained  the  embryonal  cells  and  leucocytes, 
the  latter  serving  as  food  for  the  former.  The  embryonal  connective-tissue 
cells  are  about  two  or  three  times  larger  than  the  leucocytes.  The  giant  cells 
which  are  occasionally  found  are  fibroblasts  which  have  grown  to  such  enor- 
mous proportions  by  inclusion  of  nutritive  material  derived  from  disin- 
tegrating leucocytes. 

VASCULARIZATION    OF    GRANULATION-TISSUE. 

The  vessels  which  furnish  the  blood-supply  to  the  granulation-tissue 
are  new  structures,  and  are  usually  formed  from  preexisting  vessels  in  in- 
jured vascular  tissue,  and  from  the  nearest  blood-vessels  in  non-vascular  tis- 
sue. Vessel-formation  and  tissue-proliferation  are  initiated  simultaneously, 
and  keep  pace  with  each  other  until  the  necessary  amount  of  granulation- 
tissue  has  been  produced,  when,  during  the  transformation  of  the  embryonal 
cells  into  permanent  tissue,  the  vascular  supply  is  gradually  diminished  by 
the  obliteration  and  disappearance  of  all  of  the  superfluous  vessels.  As  the 
layer  of  granulation-tissue  seldom  exceeds  more  than  ^/g  inch  in  thickness, 
the  new  vessels  always  remain  short,  and  retain  their  communication  with 
the  preexisting  vessels  from  which  they  started.  Travers,  in  his  experiments 
on  injuries  of  the  frog's  web,  has  observed  that  the  blood  in  the  divided  ves- 
sels becomes  stagnant  some  little  distance  from  the  wound.  During  this 
time  material  oozes  from  the  cut  vessels,  which  constitutes  the  primary 
wound-secretion.  Before  granulations  can  be  established  the  circulation 
must  become  restored  by  enlargement  and  multiplication  of  preformed 
vessels. 

The  capillary  vessels  which  have  been  cut  or  otherwise  injured  are 
closed  with  Nature's  hsemostatic:  a  minute  thrombus.  The  intravascular 
pressure  on  the  proximal  side  of  the  obstruction  results  in  dilatation  of  the 


VASCULARIZATION    OF    GEANULATION-TISSUE. 


17 


vessel,  which  produces  an  increased  blood-supply  to  the  part  commensurate 
with  the  increased  demand  for  nutritive  material.  The  new  blood-vessels 
are  formed  by  angioblasts,  which  are  proliferated  from  preexisting  vascular 
structures.  Arnold  has  studied  the  formation  of  new  blood-vessels  in  the 
stump  of  the  tail  of  tadpoles  after  amputation,  and  in  keratitis  vasculosa 
artificially  produced  in  the  cornea  of  rabbits.  To  the  researches  of  this  au- 
thor we  owe  most  of  the  knowledge  we  possess  on  this  subject.  The  new 
vessels  are  produced  by  the  budding  process  from  capillaries  near  the  surface 
of  the  wound.  The  bud  appears  first  as  a  circumscribed  thickening  of  the 
capillary  wall,  which  soon  projects  outward  in  the  form  of  a  triangular  cel- 


Fig.  12. — Superficial  Capillaries  of  a  Wound  Beginning  to  Granulate,  about  Forty- 
eight  Hours  after  its  Infliction.  X  350.  A,  free  surface;  B,  the  capillary  loops  all  dis- 
tended with  blood,  and  being  driven  outward  in  tortuous  festoons;  C,  embryonal  cells. 
(Hamilton.) 

hilar  mass  composed  of  angioblasts.     The  bud  is  then  transformed  into  a 
long  string,  terminating  in  a  delicate  granular  thread. 

The  base  of  such  a  projection  becomes  excavated,  and  blood  enters  from 
the  vessel  to  which  it  is  attached.  When  the  terminal  ends  of  two  of  such 
projections  meet  they  unite  and  form  an  arch,  which,  after  they  have  be- 
come permeable  to  the  blood-current,  constitute  a  capillary  loop  from  which 
branches  again  may  develop  in  the  same  manner.  The  new  channels  con- 
tain, upon  their  inner  surfaces,  nuclei  at  variable  distances,  which  subse- 
quently undergo  transformation  into  endothelial  cells.  The  adventitia  is 
formed  by  round  cells,  which  arrange  themselves  along  the  outer  surface  of 
the  new  channels.     Hunter  maintained  that  blood-vessels  are  formed  in 


18 


PEINOIPLES    OF    SUEGERT. 


granulations  independently  of  preexisting  vessels,  in  the  same  manner  as 
in  the  embryo,  and  that  they  enter  into  communication  with  the  yaseular 
system  subsequently.  Such  a  method  of  vascularization  during  post-em- 
bryonic life  is  not  proved.  A  number  of  pathologists,  and  among  them  Bill- 
roth, still  believe  that  blood-corpuscles  and  blood-vessels  can  be  produced 
from  connective  tissue.  They  claim  that  connective-tissue  cells  in  the  inter- 
capillary  spaces  enlarge,  become  branched,  and  that  by  union  between  similar 
projections  between  two  or  more  cells  hollow  spaces  are  created  which  serve 
as  blood-vessels,  while  the  nucleus  assumes  the  role  of  an  hsemapoietic  organ: 
a  process  which  is  well  illustrated  by  Fig.  14. 

Still  another  method  of  vessel-formation  in  granulations  has  been  ob- 
served and  described  by  Travers.  He  noticed  that,  when  one  of  the  new 
capillary  vessels  ruptures  and  blood  is  poured  out  into  the  granulation- 
tissue,  among  the  embryonal  cells  a  vascular  space  without  walls  is  formed. 
The  extravasated  blood,  under  these  circumstances,  did  not  disintegrate,  and 


Fig.  13.- 


-Formation  of  New  Blood-vessels  by  Budding. 
B,  after  six  hours.     {Arnold.) 


A,  after  three  hours; 


as  soon  as  the  space  came  in  contact  with  another  capillary  loop  the  wall 
gave  way  and  a  communication  was  established  between  the  two  capillary 
vessels,  and  later  the  channel  became  lined  with  endothelial  cells.  This 
method  of  vessel-formation  is  termed  canalization.  While  the  possibility 
of  the  development  of  new  vessels  independently  of  preformed  blood-vessels 
cannot  be  denied,  such  an  origin  is,  to  say  the  least,  exceedingly  rare,  and 
for  all  practical  purposes,  when  we  speak  of  vascularization  of  granulation- 
tissue  or  the  formation  of  new  blood-vessels  in  general,  we  mean  the  forma- 
tion of  new  channels  by  tissue-proliferation  from  the  walls  of  preexisting 
blood-vessels.  D.  J.  Hamilton,  author  of  the  excellent  "Text-book  of 
Pathology,"  asserts  that  the  blood-vessels  in  granulation-tissue  are  not  new, 
but  dilated,  tortuous,  preformed  vessels. 

In  wounds  that  heal  rapidly  the  existence  of  most  of  the  new  blood- 
vessels is  a  short  one.  With  the  beginning  of  cicatrization  they  disappear 
rapidly,  and  comparatively  only  a  few  of  them  remain  as  permanent  struct- 


CICATRIZATION. 


19 


ures  as  a  system  of  collateral  vessels  which  restore  indirectly  the  loss  of  con- 
tinuity between  the  divided  vessels.  A  failure  of  the  vessels  to  disappear 
after  cicatrization  has  been  completed  usually  is  an  indication  that  some 
pathogenic  microorganisms  have  become  imbedded  in  the  scar-tissue,  which 
interfere  with  the  proper  and  prompt  transformation  of  embryonal  into  per- 
manent tissue.  Such  scars  are  often  met  with  after  operations  for  tubercular 
lesions  and  after  the  healing  of  extensive  burns,  being  caused,  in  the  first 
instance,  by  the  bacillus  of  tuberculosis  and  in  the  latter  by  pus-microbes. 
The  vascular  conditions  in  granulating  surfaces  should  be  carefully  studied, 
and  in  the  treatment  due  attention  should  be  given  to  this  important  point, 
as  compression  and  position  are  potent  measures  in  improving  a  faulty  cir- 
culation, which  may  have  indefinitely  retarded  the  healing  process. 


b 


Fig.  14. — Development  of  Blood-corpuscles  in  Connective-Tissue  Cells,  and  Trans- 
formation of  the  Latter  into  Capillary  Blood-vessels.  A,  an  elongated  cell  with  a  cavity 
in  its  protoplasm  occupied  by  fluid  and  by  blood-corpuscles;  B,  a  hollow  cell,  the  nucleus 
of  which  has  been  multiplied;  the  new  nuclei  are  arranged  around  the  wall  of  the  cav- 
ity, the  corpuscles  in  which  have  now  become  discoid;  C,  shows  the  mode  of  union  of 
a  "hgemapoietic"  cell,  which,  in  this  instance,  contains  only  one  corpuscle,  with  the  pro- 
longation (BL)  of  a  previously  existing  vessel.  A  and  C,  from  the  newborn  rat;  B, 
from  fcetal  sheep.     (Fluegge.) 


CICATRIZATION. 

The  process  of  transformation  of  the  embryonal  cells  in  granulation- 
tissue  into  permanent,  fixed  tissue-cells  is  called  cicatrization.  Sir  James 
Paget  well  said  that  during  the  stage  of  the  healing  process  a  life  of  eminence 
is  changed  into  one  of  longevity.  In  tissues  endowed  with  great  vegetative 
powers  and  a  high  degree  of  adaptation,  even  large  defects  are  replaced  by 
tissue  which  resembles  to  perfection — anatomicall}^  histologically,  and  phys- 
iologically— the  injured  preexisting  tissue.  This  is  the  case  in  injuries  in- 
volving considerable  loss  of  substance  in  bone,  tendons,   and  peripheral 


20 


PKINCIPLES    OF    SUEGERY. 


nerves.     Complete  restoration  of  a  peripheral  nerve  frequently  takes  place 
after  resection  of  more  than  an  inch  of  its  continuity.     In  subcutaneous 


Fig.  15. — Granulating  Wound  Undergoing  Cicatrization.  A,  vessel  with  numerous 
lateral  branches;  granulation-cells  not  much  changed,  only  few  spindle  cells  near  the 
main  trunk;  B,  cicatrization  farther  advanced;  spindle  cells  predominate;  C,  D,  D', 
cicatrization  well  advanced;  E,  E',  epithelial  cells;  F,  hair-follicle  with  proliferation 
of  epithelial  cells  in  its  interior,  new  cells  reaching  the  surface,  G.     (Landerer.) 


CICATEIZATION. 


21 


tenotomy  the  tendon-ends  may  be  kept  separated  for  two  or  more  inches, 
and  yet  after  a  few  months  it  would  be  difficult  to  ascertain,  even  after  the 
most  careful  examination,  the  site  of  operation.  The  fractured  ends  of  a 
broken  bone  may  be  completely  separated  by  lateral  displacement  during  the 
entire  time  required  in  the  healing  process,  and  yet  they  are  firmly  united 
by  the  interposition  of  a  connecting  bridge  of  new  bone.  In  other  tissues 
endowed  with  less  reparative  energy,  as — for  instance — -the  musciilar  fibre, 
a  slight  separation  results  in  the  formation  of  cicatricial  tissue  between  the 
anatomical  structure  which  it  is  the  intention  to  unite.  By  cicatrization  is 
therefore  understood  the  completion  of  the  reparative  process,  and  the  term 
does  not  necessarily  imply  the  formation  of  a  permanent  cicatrix.  An  ideal 
healing  culminates  in  the  formation  of  tissue  which  effects  a  physiological 
restitution  of  a  defect  caused  by  injury  or  disease.    As  a  rule,  it  can  be  stated 


Fig.  16. — Embryonal  Connective-Tissue  Cell  Undergoing  Transformation  into  Mature 
State.  A,  the  cell-body;  still  contains  a  considerable  amount  of  protoplasm,  whicli,  how- 
ever, gradually  diminishes  toward  D,  where  it  represents  a  mature  connective-tissue  cell 
with  a  very  small  amount  of  protoplasm  surrounded  by  connective-tissue  fibres. 
(Ziegler.) 

that  the  result  will  be  satisfactory  in  proportion  to  the  amount  of  granula- 
tion^tissue  produced  or  required  in  the  process  of  repair.  In  an  aseptic 
wound  the  reparative  material  will  not  be  in  excess  of  the  local  demand, 
and  the  demand  will  depend  on  the  degree  of  accuracy  of  approximation 
of  the  surfaces  of  the  wound.  Cicatrization  begins  in  the  granulation-tissue 
nearest  the  preformed  vessel;  that  is,  the  margins  and  surface  of  the  wound. 

The  embryonal  connective-tissue  cells,  or  fibroblasts,  as  they  are  called, 
at  first  round,  become  elongated  with  thread-like  prolongations  from  the 
extremities.     (Fig.  16.) 

The  new  connective  tissue  contracts,  thus  bringing  the  margins  of  the 
wound  or  granulating  surface  in  closer  apposition,  and  by  its  constricting 
effect  assisting  in  the  obliteration  of  superfluous  vessels.  The  cicatrix  or 
scar  will  be  large  if  the  process  of  granulation  has  been  in  excess  of  the  de- 
mand, or  if  a  large  defect  had  to  be  healed  by  the  deposition  or  interposition 


22 


PEINCIPLES    OF    SURGERY. 


of  a  large  quantity  of  cicatricial  material.  Large  scars  should  be  prevented, 
if  possible,  by  appropriate  treatment,  as  from  the  contraction  they  give  rise 
to  distressing  deformities,  and  from  their  low  vitality  they  furnish  a  per- 
manent predisposition  to  ulcerative  processes  and  not  infrequently  become 
the  seat  of  malignant  disease.  After  the  healing  of  any  ulcer  of  considerable 
size  upon  the  mucous  surface  of  any  of  the  hollow  viscera  the  cicatricial  con- 
traction often  gives  rise  to  the  formation  of  strictures.  Nerves  appear  to 
form  in  granulations,  as  these  are  often  exceedingly  tender  to  the  touch. 
Their  existence,  however,  has  not  been  demonstrated.  The  pain  and  tender- 
ness may  be  caused  by  force  being  transmitted  to  subjacent  nerves.  Accord- 
ing to  Van  der  Kolk,  no  lymphatic  vessels  are  present  in  granulation-tissue. 


Fig.  17. — Wandering  Epithelial  Cells  from  Prog.    A,  old  epithelial  cells  upon  edge  of 
wound  of  skin,  with  proliferation  of  nucleus.     (Elebs.) 

During  the  process  of  cicatrization  all  the  embryonal  cell-elements  undergo 
transformation  into  mature  tissue,  the  fibroblasts  are  converted  into  con- 
nective tissue,  the  angioblasts  into  vessels,  the  myoblasts  into  muscle-fibres, 
the  osteoblasts  into  bone,  etc.,  each  histological  element  represented  in  the 
wound  or  defect  furnishing  the  material  for  its  own  repair. 


EPIDERMIZATION. 

A  wound  of  the  external  surface  of  the  body  can  be  said  to  have  healed 
after  the  completion  of  epidermization.  In  accordance  with  the  general  law 
of  succession  of  cells,  epidermization  takes  place  exclusively  by  proliferation 
of  preformed  epithelial  cells.  The  new  epithelial  cells  have  a  more  or  less 
rounded  shape,  and  cover  the  granulations  from  the  margins  of  the  wound, 
where  the  new  skin  appears  as  a  bluish-pink  pellicle.    At  first  they  do  not 


POSITIVE    INDICATIONS    IN    THE    TKEATMENT    OF    WOUNDS.  23 

readily  adhere  to  the  granulations,  but  appear  to  cover  them  (Fig.  15,  E'): 
later,  however,  they  throw  down  long  processes  which  penetrate  the  granu- 
lations, and  in  this  way  obtain  a  permanent  foot-hold.  New  epithelial  cells 
possess  amoebid  movements,  may  become  detached  from  the  epithelial  matrix, 
and  wander  some  distance  and  form  permanent  attachments,  and  in  such  an 
event  an  independent  centre  of  epidermization  is  established.  Migration  of 
epithelial  cells  was  first  observed  and  described  by  Klebs  in  superficial 
wounds  in  the  skin  of  the  frog.  (Fig.  17.)  The  irregular  projections  of  the 
new  skin  over  the  granulations,  so  frequently  observed  during  the  healing 
of  wounds  by  granulation,  is  undoubtedly  often  due  to  such  a  displacement 
of  embryonal  epithelial  cells.  In  granulating  surfaces  following  destruction 
of  the  skin  by  burns,  caustics,  or  ulceration,  independent  centres  of  epi- 
dermization are  often  seen  in  the  midst  of  the  field  of  granulations.  In  such 
cases  the  entire  thickness  of  the  skin  at  some  points  has  not  been  destroyed, 
and  epithelial  proliferation  takes  place  from  remaining  remnants  of  glands, 
as  is  well  shown  at  F  and  G  in  Fig.  15.  The  granulations  in  the  immediate 
vicinity  of  the  zone  of  epidermization  become  reduced  in  size,  the  blood- 
vessels are  diminished  in  number,  and  the  subjacent  fibroblasts  are  rapidly 
converted  into  connective  tissue.  In  wounds  of  the  skin  which  heal  without 
visible  granulations  the  papillae  are  absent  from  the  cicatrix,  even  though  it 
be  broad  from  subsequent  yielding  to  traction.  In  wounds  healing  by  open 
granulations  new  papillge  are  formed  in  the  new  skin,  because  the  capillary 
loops  atrophy  downward  and  become  the  papillary  vessels.  Epidermization 
and  cicatrization  are  favorably  influenced  by  measures  which  secure  for  the 
wound  an  aseptic  condition  throughout,  and  by  keeping  the  delicate  granula- 
tions covered  with  protective  silk  until  the  wound  is  completely  healed. 

POSITIVE  INDICATIONS  IN  THE  TKEATMENT  OF  WOUNDS,   WITH  SPECIAL 
EEFEKENCE  TO   SECURE  UNION  BY  FIRST  INTENTION. 

Absolute  Asepsis. — -Absolute  asepsis  can  only  he  secured  hy  strictest  anti- 
septic measures.    Surgical  cleanliness  is  more  than  ordinary  cleanliness. 

Antiseptic  precautions  are  employed  for  the  purpose  of  securing  for 
the  wound  and  everything  that  is  brought  in  contact  with  it  an  aseptic  con- 
dition. The  term  antiseptic,  used  as  a  noun,  shou.ld  be  restricted  to  agents 
which  retard  the  growth  of  pathogenic  germs,  in  contrast  with  the  term 
germicide,  which  is  applied  to  agents  which  destroy  pathogenic  microbes. 
A  solution  of  corrosive  sublimate,  when  introduced  into  a  culture  solution 
in  the  proportion  of  1  to  300,000  will  restrain  the  development  of  anthrax 
spores;  but  to  insure  the  destruction  of  these  spores  a  solution  of  1  to  1000 
must  be  used.  The  mechanical  removal  of  microbes  from  the  field  of  opera- 
tion by  shaving  and  washing  with  warm  water  and  potash-soap  should  be  as 


24  PEINCIPLES    OF    SUEGERY. 

thorough  as  possible,  but  cannot  be  relied  upon  in  securing  asepsis.  The  sur- 
face must  be  disinfected  with  a  reliable  germicidal  solution,  either  a  1-to- 
1000  solution  of  corrosive  sublimate  or  a  4-per-cent.  solution  of  carbolic  acid. 
Accidental  wounds  must  always  be  considered  as  infected  wounds,  and  a 
faithful  effort  must  be  made  to  render  them  aseptic  by  exposing,  if  possible, 
the  entire  wounded  surface  to  the  direct  action  of  one  of  these  solutions,  while 
the  surface  for  a  considerable  distance  around  it  is  also  disinfected.  Re- 
cently, a  weak  solution  of  the  double  cyanide  of  mercury  and  zinc  has  been 
recommended  by  Sir  Joseph  Lister  as  an  antiseptic,  and,  from  his  experi- 
mental investigations  and  clinical  experience,  it  appears  that  this  substance 
possesses  an  advantage  over  carbolic  acid,  corrosive  sublimate,  and  other  anti- 
septics, as  it  exerts  an  inhibitory  effect  upon  microbes  which  still  may  re- 
main in  the  wound  or  its  immediate  vicinity,  which  prevents  them  from 
multiplying  in  the  tissues  or  in  the  dressing.  At  the  present  time  many  sur- 
geons depend  almost  exclusively  on  pure  alcohol  or  a  50-per-cent.  solution 
as  an  antiseptic  for  surface  disinfection  after  thorough  scrubbing  with  hot 
water  and  potash-soap.  The  finger-nails  require  special  attention  in  hand- 
disinfection.  Fuerbringer  recommends  the  following  procedure  for  the  dis- 
infection of  the  hands:  1.  Remove  all  visible  dirt  from  beneath  and  around 
the  nails.  2.  Brush  the  spaces  beneath  the  nails  with  soap  and  hot  water 
for  a  minute.  3.  Wash  for  a  minute  in  alcohol,  and,  before  this  evaporates, 
in  the  following  solution:  4.  Wash  thoroughly  for  a  minute  in  a  solution 
containing  1  to  500  of  corrosive  sublimate  or  3  per  cent,  of  carbolic  acid. 
On  each  side  of  the  wound  or  field  of  operation  a  towel  wrung  out  of  an  anti- 
septic solution  is  spread  smoothly,  in  order  that,  during  the  operation,  in- 
struments and  sponges  will  not  be  contaminated  by  being  brought  in  con- 
tact with  non-aseptic  clothing  or  surface.  None  but  sterilized  sponges  are 
to  be  used,  and,  in  the  absence  of  such,  pieces  of  aseptic  gauze  folded  into 
convenient  shape  should  be  used  as  substitutes.  The  cheapest  and  most 
reliable  method  of  disinfection  of  instruments  is  to  boil  them  for  five  min- 
utes in  a  1-per-cent.  solution' of  carbonate  of  soda,  and  then  place  them  upon 
an  aseptic  towel,  ready  for  use.  If  these  antiseptic  precautions  have  been 
faithfully  carried  out,  sterilized  water  can  be  used  for  irrigation  during  the 
operation,  or  the  dry  method  of  operating  recently  introduced  into  practice 
by  Landerer  can  be  followed  in  operating  upon  aseptic  tissues  or  in  the  treat- 
ment of  aseptic  wounds.  In  the  operative  treatment  of  suppurative  affec- 
tions, irrigation  with  a  l-to-5000  solution  of  sublimate  must  be  frequently 
resortedto  during  the  operation,  and,  in  the  removal  of  tubercular  products, 
irrigation  with  an  aqueous  solution  of  the  tincture  of  iodine,  made  by  add- 
ing enough  of  the  tincture  to  sterilized  water  to  impart  to  the  solution  a 
sherry  color,  should  be  used. 


CAEEFUL    HJEMOSTASIS.  25 

CAEEFUL    H^MOSTASIS. 

The  presence  of  a  blood-clot  between  the  surfaces  of  the  wound  is  ob- 
jectionable for  the  following  reasons:  1.  It  separates  mechanically  the  sur- 
faces which  it  is  intended  to  unite.  2.  It  serves  as  a  culture-medium  for 
microdrganisms  which,  if  in  contact  with  living  tissue,  might  remain  harm- 
less. 3.  It  gives  rise  to  tension,  and  consequently  becomes  productive  of 
pain  and  an  undue  degree  of  reflex  irritation.  For  years  von  Bergmann  has 
insisted  that  careful  arrest  of  hsemorrhage  is  one  of  the  most  urgent  and  im- 
portant indications  in  the  treatment  of  wounds,  and  his  teachings  merit  the 
attention  of  every  prudent  surgeon.  Bleeding-points  should  be  tied  with 
sterilized  catgut  or  silk.  A  number  of  surgeons  have  discarded  catgut,  as  it 
is  more  difficult  to  render  it  aseptic  than  silk.  The  latter  can  be  readily 
sterilized  by  boiling.  The  haemorrhage  that  so  often  interferes  with  an  ideal 
healing  of  the  wound  is  the  capillary  or  parenchymatous  oozing,  and  this 
should  always  be  carefully  arrested  before  the  wound  is  sutured.  The  fol- 
lowing measures  should  be  resorted  to  in  controlling  this  form  of  bleeding, 
and  in  the  order  named:  1.  Position.  2.  Surface  compression.  3.  Hot- 
water  irrigation.     4.  Antiseptic  tampon. 

1.  In  wounds  of  the  extremities  capillary  oozing  is  usually  promptly 
arrested  by  holding  the  limb  in  a  perpendicular  position.  In  this  position 
the  intraarterial  pressure  is  diminished  and  the  return  of  venous  blood 
favored,  both  of  which  are  important  elements  in  reducing  the  amount  of 
blood  in  the  capillary  vessels.  In  order  to  produce  the  desired  efEect,  this 
position  should  be  maintained  for  fifteen  to  twenty  minutes,  and  the  limb 
should  be  kept  elevated  for  at  least  six  hours  after  the  operation. 

2.  Surface  pressure  with  a  flat  sponge  or  a  compress  mechanically 
arrests  the  bleeding,  and  the  capillary  vessels,  partly  or  completely  emptied 
of  blood,  are  placed  in  a  more  favorable  condition  for  the  formation  of  a 
thrombus.  After  an  amputation,  for  instance,  the  sponge  or  compress  is 
applied  to  the  surface  of  the  cut  muscles  and  the  flaps  are  laid  over  it  and 
compression  with  two  hands  applied,  with  the  limb  in  a  perpendicular  posi- 
tion before  the  elastic  constrictor  is  removed.  Compression,  continued  in 
this  manner  for  ten  or  flfteen  minutes,  will  usually  be  successful  in  com- 
pletely/arresting parenchymatous  bleeding. 

3.  Irrigation  with  salt  water  (sodic  chloride,  0.7  of  1  per  cent.)  at  a 
temperature  sufficiently  high  to  coagulate  the  albumen  on  the  surface  of  the 
wound  seals  mechanically  the  cut  vessels,  and,  at  the  same  time,  produces  a 
localized  anaemia  by  contracting  the  terminal  arterial  branches.  A  tempera- 
ture of  120°  F.  will  answer  for  this  purpose. 

4.  Styptics  should  never  be  employed  in  arresting  bleeding  from  a  re- 
cent wound.    If  the  procedures  mentioned  fail  in  accomplishing  the  desired 


26  PEINCIPLES    OF    SUEGEEY. 

object,  the  wound  should  not  be  sutured  until  hsemorrhage  has  been  com- 
pletely checked  by  the  use  of  the  antiseptic  tampon.  The  wound  is  packed 
with  iodoform  gauze,  and  the  customary  dressing  is  applied  in  such  a  man- 
ner as  to  exercise  uniform  gentle  pressure.  After  twenty-four  hours  the 
dressing  and  tampon  are  removed,  and  the  wound  closed  with  sutures.  In 
such  cases  secondary  suturing  is  of  great  value  in  securing  a  speedy  and  satis- 
factory healing  of  the  wound. 

ACCUEATE    SUTUEING. 

Brilliant  operators  are  not  always  the  best  surgeons.  The  dest  results  in 
surgery  follow  the  one  who  is  most  painstahing  in  following  out  the  minutest 
details.  This  assertion  applies  most  forcibly  in  the  treatment  of  wounds. 
The  surgeon  here  occupies  the  position  of  handmaid  to  the  vis  medicatrix 
naturce,  and  in  the  exercise  of  his  duties  must  do  all  in  his  power  to  tax 
only  to  a  minimum  extent  the  regenerative  resources  of  the  wounded  tissues. 
In  the  treatment  of  wounds  it  becomes  his  imperative  duty  not  only  to  unite 
the  surfaces  of  the  wound  accurately  and  neatly,  but  to  unite,  whenever  it 
.  becomes  necessary,  tissues  of  the  same  anatomical  structure  and  physiological 
function.  Divided  nerves,  tendons,  muscles,  fascia,  must  be  separately  united 
with  absorbable  buried  sutures  before  the  wound  is  closed  by  the  ordinary 
interrupted  or  continuous  suture.  When  several  nerves  or  tendons  have  been 
divided  in  the  same  wound,  great  care  must  be  exercised  to  unite  the  ends 
of  the  same  nerve  or  tendon.  Accurate  approximation  of  a  deep  wound  is 
impossible  without  the  buried  suture.  Several  rows  of  these  sutures  may  be 
required.  Eeliable  catgut  should  be  preferred  for  the  deep  sutures,  but  if 
this  material  is  not  at  hand  fine  silk  can  be  used.  The  best  materials  for 
the  ordinary  interrupted  sutures  are  silk  or  silk-worm  gut.  Separate  sutures 
for  the  skin  are  usually  required  in  order  to  approximate  the  superficial  mar- 
gins of  the  wound  accurately,  and  for  this  purpose  horse-hair  is  the  most 
desirable  material.  If  the  surgeon  has  reason  to  believe  that  the  wound  is 
aseptic,  drainage  should  be  dispensed  with,  because  the  manner  of  suturing, 
as  just  described,  guards  against  the  occurrence  of  "dead  spaces."  An  ab- 
sorbent antiseptic  compress,  composed  of  a  few  layers  of  iodoform  gauze  and 
a  thick  layer  of  salicylated  cotton,  or  sublimated  moss  or  wood-wool,  is  the 
most  appropriate  dressing  for  such  cases.  The  gauze  bandage  to  retain  this 
dressing  is  applied  in  such  manner  as  to  exercise  uniform  equable  compres- 
sion: an  important  element  in  affording  support  to  the  injured  vessels  and 
in  securing  rest  for  the  parts  involved  in  the  injury.  Fixation  of  the  wounded 
part  by  splints  to  secure  rest  and  elevation  to  influence  favorably  the  cir- 
culation are  likewise  important  measures  in  aiding  the  process  of  repair  by 
insuring 


UNIOK    BY    SECONDAEY    INTENTION.  37 


PHTSIOLOGICAL    REST. 


In  the  after-treatment  of  a  wound  nothing  is  more  important  than  to 
secure  for  the  parts  which  have  been  mechanically  united,  as  far  as  possible, 
physiological  rest.  The  importance  of  rest  in  the  prevention  and  treatment 
of  inflammation  has  been  prominently  brought  forward  by  Hilton,  and  his 
teachings  have  resulted  in  a  great  deal  of  good  in  the  treatment  of  inflam- 
matory surgical  affections.  If  one  of  the  extremities  is  the  seat  of  the  wound, 
immobilization  upon  a  splint  or  with  a  plaster-of-Paris  dressing,  in  such  a 
position  as  to  relax  the  muscles  involved  in  the  wound,  is  of  paramount  im- 
portance. The  injured  part  must  be  kept  in  a  position  which  will  favor  a 
normal  blood-supply  and  prevent  passive  hypersemia.  A  wound  properly 
dressed  should  not  be  disturbed  until  union  has  taken  place.  If  any  one  of 
the  three  most  important  indications  for  a  change  of  dressing — pain,  rise 
in  temperature,  and  saturation  of  the  dressing  with  wound-secretions — do 
not  arise,  the  first  dressing  is  allowed  to  remain  for  eight  days  to  six  weeks, 
according  to  the  location,  character,  or  size  of  the  wound.  In  wounds  of 
the  gastro-intestinal  canal  physiological  rest  is  secured  by  abstinence  from 
food,  and,  if  necessary,  peristalsis  is  diminished  by  a  few  doses  of  opium. 
In  wounds  of  the  bladder  distension  of  the  organ  is  prevented  by  the  intro- 
duction and  retention  of  a  catheter.  In  wounds  of  the  brain  or  its  envelopes 
rest  is  secured  by  exclusion  of  light  and  by  enforcing  quietude  in  the  patient's 
room. 

UNION    BY    SECONDARY    INTENTION. 

In  an  aseptic  wound  all  the  new  material  resulting  from  proliferation 
of  the  fixed  tissue-cells  is  used  in  the  process  of  repair,  and  the  time  for 
healing  of  the  wound  will  depend  on  the  anatomical  structure  of  the  part 
injured  and  the  amount  of  material  required  to  form  a  bridge  of  living  tis- 
sue between  the  divided  parts.  As  long  as  the  wound  heals  without  destruc- 
tion of  any  of  the  new  tissue-elements  by  specific  microbic  causes,  it  is  proper 
to  speak  of  a  union  by  primary  intention,  whether  the  healing  is  completed 
in  three  or  four  days  or  whether  it  is  protracted  for  months  until  the  ulti- 
mate object  of  wound  treatment  has  been  reached.  From  a  pathological, 
and  even  from  a  practical,  stand-point,  it  is  not  correct  to  include,  under  the 
head  of  healing  by  the  second  intention,  aseptic  wounds  that,  on  account  of 
want  of  proper  approximation,  or  on  account  of  loss  of  tissue,  have  of  neces- 
sity to  heal  by  granulation,  with  infected  wounds  in  which  the  regenerative 
processes  are  disturbed  by  suppuration.  In  a  suppurating  wound  the  em- 
bryonal cells  which  are  destined  to  become  transformed  into  new  tissue  are 
exposed  to  the  destructive  action  of  pus-microbes  and  their  toxins,  their 
protoplasm  is  destroyed,  and  they  become  one  of  the  histological  sources  of 
pus-corpuscles.    The  cells  on  the  surface  of  the  wound,  being  most  distant 


28  PEINCIPLES    OF    SUEGERY. 

from  the  vascular  supply,  possess  the  least  power  of  resistance  to  the  action 
of  pus-microbes,  and  on  this  account,  as  well  as  from  the  greater  number  of 
pus-microbes  on  the  surface  of  the  wound  than  in  the  deeper  tissues,  they 
are  converted  into  pus-corpuscles.  As  long  as  suppuration  remains  active 
the  superficial  layer  of  granulation-cells  is  destroyed,  and  as  soon  as  other 
embryonal  cells  take  their  place  the  process  is  repeated,  and  thus  the  healing 
of  the  wound  is  indefinitely  delayed. 

When  a  favorable  change  takes  place  in  the  wound,  either  spontaneously 
or  from  the  employment  of  antiseptic  measures,  suppuration  is  diminished, 
the  granulations  become  firmer  and  more  vascular,  and  cicatrization  and  epi- 
dermization  now  progress  in  a  satisfactory  manner.  Such  a  favorable  change 
in  the  condition  of  the  wound  can  be  readily  explained  after  the  use  of  such 
agents  as  are  known  to  destroy  the  microbic  cause  of  the  suppuration  when 
brought  in  contact  with  the  .wound.  In  such  a  case  we  would  naturally 
expect  that,  with  the  removal,  destruction,  or  rendering  inert  of  the  pus- 
microbes,  the  embryonal  cells  would  remain  attached  to  the  point  where  they 
were  produced,  and  would  soon  be  converted  into  tissue  resembling  the 
matrix- which  produced  them.  Spontaneous  cessation  of  suppuration,  and 
with  it  the  conversion  of  .a  surface  covered  with  dead  material  into  a  healthy, 
granulating  surface,  would  indicate  either  that  the  virulence  of  the  pus- 
microbes  had  become  attenuated,  that  the  soil  was  no  longer  congenial  for 
their  multiplication,  or  finally  that  the  resistance  on  the  part  of  the  tissues 
to  their  pathogenic  action  had  become  increased.  That  tissue-resistance  has 
a  potent  influence  in  neutralizing  and  modifying  the  action  of  pathogenic 
microorganisms  has  been  observed  clinically  and  demonstrated  experiment- 
ally. Suppurating  wounds  are  graver  affections,  and  are  more  difficult  to 
manage  in  the  aged  and  in  badly-nourished  persons,  as  well  as  in  patients 
debilitated  from  all  kinds  of  excesses  and  protracted  diseases.  A  good  cir- 
culation of  the  part  is  an  important  element  in  counteracting  the  cause  of 
suppuration.  A  chronic  varicose  ulcer  of  the  leg  that  suppurates  freely,  as 
long  as  the  patient  continues  to  use  the  limb,  is  often  transformed  into  a 
healthy  granulation-surface  after  a  few  days  of  rest  in  bed  with  the  affected 
limb  in  an  elevated  position. 

TEEATMENT   OF  SUPPUEATING  V70UNDS,   V^ITH  SPECIAL  EEFEEENCE 
TO    HASTENING   THE    PROCESS    OF   EEPAIE. 

In  the  treatment  of  an  accidental  wound,  which  always  must  be  re- 
garded as  a  septic  wound,  or  in  the  management  of  a  wound  where  the  anti- 
septic precautions  have  failed,  no  time  should  be  lost  in  securing  for  the 
wound  and  its  vicinity  an  aseptic  condition  by  thorough  disinfection.  The 
surroundings  of  the  wound  are  disinfected  in  the  same  manner  as  for  an 
operation.    The  wound  is  exposed  as  thoroughly  as  possible  to  direct  treat- 


SUTUKING    OF    GEANULATING   WOUNDS.  .  39 

ment  by  enlarging  it  over  recesses  otherwise  inaccessible,  after  which  it  is 
thoroughly  irrigated  with  jseroxide  of  hydrogen,  followed  by  a  solution  of 
sublimate  (1  to  2000)  or  carbolic  acid  (3  V2  to  5  per  cent.).  If  the  granula- 
tions are  copious  and  flabby,  they  must  be  removed  with  Volkmann's  sharp 
spoon,  and  after  the  bleeding  has  ceased  a  12-per-cent.  solution  of  chloride 
of  zinc  is  applied;  after  a  few  minutes  the  surplus  fluid  is  washed  away  by 
irrigation  with  the  sublimate  or  carbolic  solution.  The  wound  is, now  dried, 
sutured,  and  drained.  Drainage  in  these  cases  is  a  necessary  evil,  as  the 
surgeon  can  never  feel  certain  that  he  has  succeeded  in  obtaining  perfect 
asepsis.  If  the  wound  is  extensive,  or  if  pus  has  been  burrowing  in  different 
directions  along  the  deep  tissues,  as  in  cases  of  compound  fracture  where  a 
thorough  disinfection  of  every  part  of  the  wound,  as  already  described,  is 
impossible  or  impracticable,  constant  irrigation  with  a  saturated  solution  of 
acetate  of  aluminum  or  Thiersch's  solution  should  be  instituted  and  con- 
tinued until  the  wound  has  been  rendered  aseptic.  Acetate  of  aluminum  is 
a  reliable  antiseptic,  is  non-toxic,  and  penetrates  the  tissues  deeply.  The 
treatment  most  appropriate  for  a  recent  aseptic  wound  is  to  be  adopted  as 
soon  as  suppuration  has  ceased  and  the  general  symptoms  at  the  same  time 
point  to  an  aseptic  condition. 

SUTURING    OF    GRANULATING    WOUNDS. 

If  union  by  primary  intention  has  failed  to  take  place,  for  any  reason, 
in  wounds  which  can  be  closed  by  suturing,  a  second  attempt  can  be  made 
to  approximate  the  surfaces  with  sutures,  with  fair  prospects  of  success  as 
soon  as  the  granulations  are  in  an  aseptic  condition.  Aseptic  granulating 
surfaces  when  brought  in  contact  unite  rapidly,  as  vascular  connections  be- 
tween the  new  capillary  loops  are  established  in  a  remarkably  short  time, 
and  the  wound  then  heals  in  the  same  manner  as  after  primary  suturing. 
The  cases  best  adapted  for  secondary  suturing  are  those  where  suppuration 
has  ceased,  the  granulations  have  become  small  and  firm, — in  short,  wounds 
in  which  cicatrization  has  commenced.  The  technique  in  the  treatment  of 
such  wounds  is  the  same  as  in  cases  of  aseptic  recent  wounds.  The  advan- 
tages of  this  method  of  dealing  with  wounds  that  have  failed  to  unite  are 
pronounced  when  the  wound  is  deep  and  the  margins  can  be  coaptated  with- 
out much  tension.  Buried  sutures  can  be  used  for  the  same  purpose  and 
with  the  same  benefit  as  in  the  treatment  of  recent  wounds.  Before  the  sur- 
faces are  brought  in  contact  with  the  sutures  it  is  important  to  disinfect  and 
dry  the  granulations  thoroughly.  As  secondary  suturing  is  applicable  only 
in  the  treatment  of  such  wounds  where  we  have  every  reason  to  assume  that 
an  aseptic  condition  exists  or  can  be  secured  by  disinfection,  the  whole  wound 
should  be  carefully  closed  and  drainage  must  be  dispensed  with,  in  order  to 


30  PEINCIPLES    OF    SUEGEEY. 

obtain  rapid  healing  of  the  entire  wound.  It  has  been  recently  suggested 
by  Hahn  that  in  extensive  defects  of  the  skin  a  covering  for  the  wound  can 
be  obtained  by  sliding  of  the  skin,  after  undermining  it  for  some  distance, 
in  a  direction  most  suitable.  That  this  procedure  is  applicable  only  under 
circumstances  when  the  surgeon  is  sure  of  asepsis  is  to  be  taken  for  granted, 
as  otherwise  it  might  be  followed  by  gangrene  and  still  greater  loss  of  tissue. 


CHAPTER  II. 

Regeneeation  of  Different  Tissues. 

In  connection  with  the  subject  of  healing  of  wounds  it  is  very  im- 
portant for  the  student  to  familiarize  himself  with  the  vegetative  capacity 
of  the  different  tissues  of  the  body  in  order  to  estimate  with  some  degree 
of  accuracy  the  part  taken  by  each  tissue  in  the  reparative  processes  which 
take  place  after  an  injury  or  disease.  No  'positive  -proof  has  yet  he&n  furnished 
that  the  leucocytes  or  any  other  of  the  cellular  elem&nis  of  the  Hood  take  any 
active  part  in  the  restoration  of  lost  parts.  It  does  not  appear  to  me  reason- 
able or  logical  that  such  an  indifferent  cell  as  the  leucocyte  should  ever  be- 
come transformed  directly  into  a  fixed  tissue-cell,  and  it  is  still  more  im- 
probable that  it  should  be  possessed  with  such  a  diverse  vegetative  capacity 
as  to  undergo  a  transition  in  one  place  into  a  connective-tissue  cell,  in  an- 
other into  bone,  and  still  another  into  a  muscle-fibre.  It  is  much  more 
rational  to  assume,  in  the  repair  of  an  injury  and  in  the  regeneration  of  a 
part  destroyed  by  disease,  that  the  universal  law  of  legitimate  succession  of 
cells  asserts  itself,  according  to  which  the  reparative  process  is  initiated  and 
completed  by  homologous  cell-proliferation. 

In  the  following  pages  experimental  and  clinical  proofs  will  be  ad- 
vanced which  will  at  least  tend  to  establish  the  truth  of  this  assertion. 

NON-VASCULAR   TISSUE. 

The  part  taken  by  blood-vessels  in  regenerative  processes  is  well  shown 
in  the  healing  of  wounds  of  non-vascular  tissue.  Large  wounds  of  the  cornea 
and  cartilage  can  only  heal  after  a  blood-supply  has  b^en  established  through 
new  vessels  from  the  nearest  vascular  district.  Rapid  vascularization  of  the 
non- vascular  tissues  is  always  observed  when  the  wound  has  become  infected. 

Cornea.  — -  The  normal  cornea  contains  no  blood-vessels,  but  vascular 
spaces,  which  form  a  system  of  channels  for  the  circulation  of  the  plasma- 
fluid.  In  1863  Recklinghausen  discovered  in  these  spaces  migrating  cor- 
puscles, resembling  in  size  and  shape  the  white  blood-corpuscles,  which  he 
regarded  as  offspring  of  the  corneal  corpuscles.  Later,  Cohnheim  showed 
that  these  wandering  cells  were  leucocytes  which  had  escaped  from  the  peri- 
corneal capillary  vessels  and  had  found  their  way  into  these  channels.  In 
traumatic  keratitis  these  spaces  become  blocked  with  leucocytes,  and  they 
constitute  largely  the  primary  product  of  inflammatory  exudation  long  be- 
fore the  fixed  cells  of  the  cornea  could  have  yielded  such  an  amount  of  cel- 
lular elements.     Strube  and  His  studied  experimentally  the  healing  of 

(31)        . 


33  PKINCIPLES    OF    SUEGERY. 

"wounds  of  the  cornea  and  traumatic  keratitis.  They  injured  the  cornea  of 
rabbits  by  cutting  and  cauterization.  As  the  cornea  is  freely  supplied  with 
nerves,  they  observed  as  one  of  the  earliest  tissue-changes  a  reflex  paretic 
dilatation  of  the  marginal  blood-vessels.  The  marginal  hyperaemia  was  fol- 
lowed by  the  formation  of  new  blood-vessels  in  the  direction  of  the  seat  of 
injury.  The  early  opacity  around  the  wound  and  the  space  between  the 
wound  and  the  advancing  channels  are  caused  by  the  presence  of  leucocytes 
in  the  vascular  spaces;  later,  to  proliferation  of  the  corneal  corpuscles.  That 
leucocytes  enter  the  plasma-canals  when  the  cornea  is  irritated  has  been 
definitely  settled  by  Cohnheim  by  one  of  his  most  ingenious  experiments. 
He  injected  finely-divided  carmine  suspended  in  an  acid,  or  precipitated 
aniline  into  the  dorsal  lymph-sacs  of  frogs,  with  the  result  that  when  he 
irritated  the  cornea,  a  few  days  later,  leucocytes  stained  with  the  pigment- 
material  appeared  at  the  margin  of  the  cornea  where  cell-migration  was 
known  to  appear  first.  He  found  a  rapid  increase  of  corneal  corpuscles  in 
the  animal  subjected  to  experimentation;  thus,  in  one  instance,  eighteen 
hours  after  the  injury,  he  found,  in  spaces  normally  occupied  by  one  cor- 
puscle, as  many  as  twenty  to  thirty  young  cells  closely  packed  together. 

D.  J.  Hamilton  regards  as  the  first  change  in  an  irritated  cornea  an 
increase  of  the  plasma-current,  which  may  destroy  the  endothelial  lining  of 
the  canals,  and  according  to  this  observer  cell-migration  into  the  corneal 
spaces  occurs  later.  Unimpaired  innervation  of  the  cornea  is  an  important 
factor  in  the  prompt  healing  of  wounds  of  this  structure,  as  it  is  well  known 
that  in  patients  suffering  from  glaucoma,  and  in  the  aged,  wounds  of  the 
cornea  heal  often  in  a  very  unsatisfactory  manner.  An  aseptic  wound  of  a 
normal  cornea  heals  without  opacity;  the  new  corneal  corpuscles,  after  they 
attain  maturity,  transmit  light  as  perfectly  as  the  cells  from  which  they  are 
produced.  Imperfect  restoration  of  tissue  is  to  be  expected  when  the  regen- 
erative process  is  complicated  by  a  suppurative  inflammation  with  consid- 
erable destruction  of  tissue.  Gussenbauer  incised  the  cornea  in  rabbits  half- 
way between  the  centre  and  its  margin  to  the  extent  of  half  a  line  to  a  line, 
and  found,  in  examining  the  specimens  after  twenty-four  hours,  that  no 
union  had  taken  place.  The  wound-surfaces  at  this  time  were  glued  together 
by  an  interposed  substance.  The  surfaces  of  the  wound  were  in  close  con- 
tact at  a  point  corresponding  to  the  middle  portion  of  the  cornea,  and  the 
gap  widened  toward  each  of  its  surfaces,  so  that  the  temporary  cement-sub- 
stance represented  two  cones  with  their  apices  directed  towa,jd  each  other 
and  the  bases  toward  the  surfaces.  On  staining  the  specimens  with  chloride 
of  gold  it  was  found  that  this  substance  contained  cells  which  were  most 
numerous  toward  the  surfaces  of  the  cornea.  The  corneal  corpuscles  on  the 
cu.t  surfaces  were  seen  to  be  enlarged  and  presenting  different  stages  of  cell- 
division.     Instead  of  round,  the  corpuscles  were  spindle-shaped,  some  con- 


NON-VASCULAK   TISSUE. 


33 


taining  one  nucleus,  others  two  nuclei;  intercellular  substance  granular. 
In  specimens  eight  days  old  the  space  between  the  cut  surfaces  was  occupied 
almost  exclusively  by  new  corneal  corpuscles^  and  the  edges  of  the  wound 
could  no  longer  be  clearly  defined.  During  cicatrization  of  the  wound  the 
number  of  cells  is  diminished,  while  in  form  and  size  they  resemble  more 
and  more  the  mature  corneal  corpuscles  from  which  they  Avere  derived. 

In  a  non-penetrating  incised  wound  of  the  cornea  the  gap  is  filled  up 
after  a  few  days  with  young  cells  derived  from  the  cylindrical  cells  of  the 
deepest  layer  of  the  corneal  epithelia. 

If  the  wound  has  penetrated,  the  posterior  third  of  the  wound  gapes 
toward  the  anterior  chamber  of  the  eye,  and  is  first  plugged  with  the  prod- 
ucts of  coagulation-necrosis,  which  is  later  replaced  by  epithelial  cells  from 
the  membrana  Descemeti  (Fig.  19,  C),  while  the  anterior  portion  is  occupied 
by  epithelial  cells  the  same  as  in  the  non-penetrating  wounds.     At  the  end 


Fig.  18.— Corneal  Corpuscles  in  a  State  of  Proliferation.    A,  old  corneal  corpuscles 
with  one  or  two  nuclei  and  young  offshoots,  B  and  C.    (Senftleben.) 

of  the  first  week  the  corneal  corpuscles  begin  to  proliferate,  and  the  cells 
from  this  source  gradually  displace  the  epithelial  cells  and  bring  about  the 
definitive  healing  of  the  wound.  As  wounds  of  the  cornea  are  not  sutured, 
the  surgeon  should  aim  to  secure  approximation  by  removing  coagulated 
blood,  if  present,  and  by  correcting  any  existing  displacements  by  di- 
rect measures,  and  finally  by  applying  a  dressing  which  will  exert  uniform 
and  equable  elastic  compression.  Although  the  antiseptic  treatment  cannot 
be  carried  out  with  the  same  precision  in  the  treatment  of  wounds  of  the 
cornea  as  in  other  localities,  it  is  at  least  the  duty  of  the  surgeon  to  use  only 
sterilized  instruments  and  aseptic  sponges,  and  to  employ  such  mild  anti- 
septic solutions  as  will  at  least  exercise  an  inhibitory  influence  upon  pathog- 
enic microorganisms  that  may  be  present  in  the  wound  or  upon  the  surface 
of  the  eye. 

Cartilage.  —  Cartilage  is  in  every  sense  of  the  word  a  non-vascular 
structure,  as  even  the  plasma-channels  found  in  the  cornea  are  absent  here. 


34 


PEINCIPLES    OF    SUEGEEY. 


Plasma-diffusion  must  take  place  between  or  through  the  cells.  It  is  un- 
doubtedly on  account  of  the  limited  provisions  for  nutritive  supply  that  the 
vegetative  capacity  of  this  tissue  is  so  exceedingly  low.  Normal  cartilage 
when  injured  is  unable  to  repair  the  defect.  The  process  of  healing  of 
wounds  of  cartilage  was  first  studied  experimentally  by  Redfern.  In  one 
experiment  he  found  the  wound  almost  unchanged  after  twenty-nine  days. 
In  one  specimen,  where  the  healing  process  had  been  completed,  he  found 
the  defect  repaired  by  connective  tissue.  The  microscopical  description  of 
the  healing  process  corresponded  with  that  given  by  Goodsir  of  inflammatory 


Fig 


19. — Wound  of  Cornea.    A- A',  new  corneal  corpuscles;    B-A',  temporary  plug  of 
fibrin;    G,  epithelia  from  membrana  Descemeti.    (Von  Wyss.) 


processes  in  this  structure.  iVlong  the  margins  of  the  wound  the  cartilage- 
cells  multiply  and  the  cement-substance  is  dissolved.  No  new  cartilage-cells 
are  produced,  and  the  space  is  occupied  by  connective  tissue.  Vasculariza- 
tion toward  the  seat  of  injury  from  the  marginal  vessels  of  the  perichon- 
drium takes  place  in  the  same  manner  as  in  the  cornea.  Eeitz  traced  the 
formation  of  connective  tissue  from  the  cartilage-cells  in  tracheotomy 
wounds  in  rabbits.  He  observed,  after  the  cement-substance  had  become 
dissolved,  that  the  cartilage-cells  were  transformed  into  spindle  cells,  and 
later  into  connective  tissue.  He  found  the  gap  between  the  divided  carti- 
lage-ring filled  with  such  cells  a  few  days  after  the  wound  had  been  inflicted, 


VASCULAE    TISSUE.  35 

and  explains  the  discrepancy  between  the  results  he  obtained  and  those 
described  by  Eedfern  on  the  gronnd  of  the  close  proximity  of  vascular  sup- 
ply in  his  case  and  the  remoteness  of  vessels  from  the  wound  studied  by 
Redfern,  as  the  latter  experimented'  on  articular  cartilage.  Gussenbauer 
studied  the  repair  of  cartilage  wounds  after  incising  subcutaneously  costal 
cartilage.  In  wounds  twenty-four  hours  old  a  triangular  gap  was  found  filled 
with  fibrin  and  blood-corpuscles.  No  change  was  found  at  this  time  in  the 
cartilage-cells  and  cement-substance.  The  cells  of  the  perichondrium  in- 
creased in  volume  and  changed  in  form.  Gussenbauer  was  unable  to  verify 
the  observation  made  by  Eeitz  in  wounds  of  trachea,  that  cartilage-cells  are 
transformed  into  connective-tissue  cells,  and  believes  that  the  ammonia  used 
by  Eeitz  to  provoke  croupous  pnevimonia,  by  its  introduction  into  the  bron- 
chial tubes  through  the  tracheal  wound,  may  have  modified  the  result.  He 
traces   tissue-proliferation   almost   exclusively   to   the    perichondrium,   the 


Fig.  20. — Healing  of  Experimental  Fracture  of  the  Tibia  of  a  Rabbit.    A,  young  fibrous 
tissue.    Ji,  osteoid  tissue  forming  by  metaplasia  from  C,  cartilage.     X  250. 

cells  of  which  were  found  in  all  stages  of  division  and  development,  while 
only  a  few  of  the  cartilage-cells  presented  evidences  of  segmentation.  Uorner 
studied  not  only  the  manner  of  repair  of  simple  incised  wounds  of  cartilage, 
but  also  produced  more  complicated  injuries,  and  invariably  found  that  the 
perichondrium  took  a  more  active  part  in  the  process  of  healing  than  the 
cartilage-cells.  Wounds  of  fibro-  and  reticulated  cartilage  heal  in  the  same 
manner  as  wounds  of  hyaline  cartilage.  The  histological  changes  observed 
by  Eedfern,  Dorner,  and  Gussenbauer  during  the  repair  of  wounds  of  carti- 
lage are  descriptive  of  the  changes  which  attend  chondritis. 

VASCULAE    TISSUE. 

The  healing  of  wounds  of  vascular  tissue  is  accomplished  more  rapidly 
than  of  non-vascular  tissue,  as  the  primary  wound-secretion,  which  is  derived 
mostly  from  the  wounded  vessels,  forms  a  temporary  cement-substance  which 
glues  the  parts  together, — a  condition  which  renders  material  assistance  in 


36  PRINCIPLES    OF    SUEGERY. 

maintaining  coaptation, — while  the  direct  blood-suppl}^  to  the  injured  part 
cannot  fail  in  increasing  the  vegetative  capacity  of  the  cells,  and,  lastly,  the 
leucocytes  present  in  the  recent  wound  serve  as  food  for  the  cells  which  are 
undergoing  karyokinetic  changes.  As  a  rule,  to  which  there  are  few  ex- 
ceptions, it  may  be  stated  that  the  rapidity  with  which  the  healing  process 
is  completed  is  proportionate  to  the  vascularity  of  the  wounded  part.  For 
instance,  wounds  of  the  fingers  heal  much  more  rapidly  than  wounds  of  the 
arm  or  forearm,  and  wounds  of  the  face  more  rapidly  than  wounds  of  the 
neck.  Karyomitotic  changes  are  first  noticed  in  the  nuclei  of  cells  in  close 
-proximity  to  blood-vessels.  In  studying  the  healing  of  wounds  of  vascular 
tissue,  Graser  noticed  that  the  connective-tissue  cells  a  little  distance  from 
the  surface  of  the  wound  were  first  to  show  evidences  of  karyokinetic  changes; 
hence,  it  is  apparent  that  the  reparative  process  is  initiated  in  cells  most 
favorably  located  in  reference  to  an  abundant  blood-supply,  which  corre- 
sponds to  the  location  of  capillary  vessels  which  are  undergoing  dilatation 
prior  to  the  formation  of  new  blood-vessels.  Eegeneration  of  tissue  takes 
place  most  rapidly  in  parts  where  new  blood-vessels  are  developed  early, 
rapidly,  and  abundantly.  The  healing  process  is  retarded  or  completely  sus- 
pended when  the  capillary  vessels,  new  and  old,  are  seriously  altered  by  in- 
flammation. 

Surface  Epithelia. — Epithelial  cells  in  a  normal  condition  receive  no 
direct  blood-supply,  but  their  relations  to  the  subjacent  vascular  tissue  are 
so  intimate,  and  their  proliferation  in  the  healing  of  surface  wounds  and 
in  the  repair  of  defects  caused  by  pathological  conditions  is  so  largely  de- 
pendent on  the  development  of  new  blood-vessels,  that  the  study  of  their 
regeneration  among  the  vascular  tissues  appears  appropriate.  In  the  con- 
sideration of  this  subject  of  epidermization,  it  has  been  shown  that  epithelial 
cells  are  derived  exclusively  from  an  epithelial  matrix,  either  from  the  mar- 
gin of  the  wound  or  an  islet  of  the  epiblast  buried  among  the  granulations. 
Loeb  has  very  recently  advanced  the  theory  that  under  certain  conditions 
connective  tissue  can  be  produced  from  epithelial  cells,  but  more  experi- 
mental proof  is  required  to  disprove  the  law  of  the  specific  histological  func- 
tion of  cell  growth  and  reproduction  established  by  Eemak.  Eegeneration 
of  epithelial  cells  of  the  hypoblast  takes  place  in  a  similar  manner  as  has 
been  described  in  epidermization  of  a  wound  of  the  cutaneous  surface.  Of 
special  interest  is  the  rapid  regeneration  of  the  gastro-intestinal  mucous 
membrane.  A  recent  gastric  or  intestinal  ulcer  presents  elevated  and  swollen 
margins,  and,  as  long  as  this  condition  remains,  the  healing  process  fails  to 
become  established  until  the  swelling  subsides,  and  paving  of  the  granula- 
tions with  epithelial  cells  is  postponed  until  the  surface  of  the  ulcer  is  nearly 
on  the  same  level  with  the  surrounding  border  of  the  mucous  membrane. 
Griffini  and  Vassale  made  gastric  fistulse  in  dogs  for  the  purpose  of  studying 


VASCULAR   TISSUE.  37 

directly,  and  during  the  life  of  the  animals,  the  process  of  repair  of  wounds 
of  the  mucous  membrane  of  the  stomach.  Through  the  fistulse  they  made 
superficial  wounds  of  the  inner  surface  of  the  organ,  and  from  their  observa- 
tions they  satisfied  themselves  that  healing  takes  place  rapidly,  and  that  re- 
generation of  epithelial  cells  occurs  in  the  peptic  glands,  where  even  as  early 
as  the  third  day  the  epithelial  cells  showed  evidences  of  active  proliferation. 
The  new  epithelial  cells  spread  over  the  interglandular  spaces,  while  a  part 
of  the  glandular  structure  is  lost  during  the  process  of  healing.  In  traumatic 
defects  where  the  glands  have  been  excised  with  the  mucous  membrane  the 
epithelial  covering  of  the  granulating  surface  is  derived  from  the  preformed 
epithelial  cells  of  the  mucous  membrane  bordering  the  wound.  At  a  later 
stage  new  glands  are  formed  by  karyomitotic  cellular  changes  after  the  nor- 
mal type  of  development  of  glands  in  the  embryo.  Even  the  youngest  glands 
have  an  outlet,  and  the  structure  increases  in  depth  by  extension  of  mitotic 
changes  in  that  direction.  Pepsin-secreting  cells  are  found  only  after  the 
glands  have  attained  nearly  their  normal  depth.  In  one  instance  they  were 
found  only  partly  developed  on  the  fortieth  day.  Connective-tissue  prolifera- 
tion takes  no  essential  part  in  the  growth  and  development  of  the  new  glands. 
Visceral  wounds  of  the  stomach  heal  kindly  and  rapidly.  Even  gunshot 
wounds  of  this  organ,  when  made  with  a  small  bullet,  may  heal  without  sur- 
gical interference,  more  especially  if  at  the  time  the  injury  has  been  in- 
flicted the  stomach  is  empty  and  all  food  is  withheld  for  a  few  days.  A  strict 
diet  is  important  in  the  treatment  of  wounds  or  ulcers  of  the  stomach,  as 
Leube  has  obtained  excellent  results  from  treatment  of  chronic  ulcers  of 
this  organ  by  an  exclusive  milk  diet.  Griffini  also  made  the  observation  that 
the  traumatic  defects  which  he  produced  in  the  interior  of  the  stomach  of 
dogs  healed  most  rapidly  when  food  was  withheld  entirely  for  a  few  days,  and 
later  on  nothing  but  milk  was  allowed.  From  these  observations  and  ex- 
periments it  is  evident  that  the  young  cells  are  unfavorably  affected  by  the 
action  of  the  gastric  juice. 

Quincke  has  demonstrated  experimentally,  which  has  been  a  long- 
known  and  familiar  clinical  fact,  that  anaemia  retards  regeneration  of  the 
gastro-intestinal  mucous  membrane.  In  two  dogs  a  gastric  fistula  was  made, 
and  through  it  a  defect  of  the  mucous  lining  was  made  of  the  same  size  in 
both  animals.  One  of  the  animals  was  in  perfect  health,  and  healing  was 
completed  in  eighteen  days.  The  other  dog  was  anaemic,  and  the  healing 
process  was  prolonged  thirty-one  days.  In  the  healing  of  an  ulcer  of  the 
stomach  or  any  portion  of  the  intestinal  canal  the  epithelial  cells  are  first  to 
take  an  active  part  in  establishing  a  process  of  repair,  the  connective-tissue 
cells  entering  later  upon  their  part  of  tissue-production.  The  healing  process 
terminates  most  satisfactorily  when  only  a  small  amount  of  connective  tissue 
is  formed  and  the  epithelial  covering  is  completed  in  a  short  time,  as  such  a 


38  PKINCIPLES    OF    SURGERY. 

scar  represents  almost  to  perfection  the  normal  tissue  it  has  replaced.  If 
a  large  quantity  of  granulation-tissue  is  produced  by  the  connective  tissue, 
and  the  formation  of  the  epithelial  covering  is  delayed  for  a  long  time,  or  is 
imperfectly  accomplished,  there  is  great  danger  of  subsequent  cicatricial 
contraction  of  the  new  tissue,  producing  a  stricture.  The  best  possible 
prophjdactic  means  against  the  occurrence  of  strictures  under  such  circum- 
stances are  such  dietetic  and  therapeutic  measures  as  will  secure  for  the 
ulcerated  or  wounded  surface  such  favorable  conditions  as  will  expedite  the 
paving  of  the  surface  with  •epithelial  cells  and  limit  the  production  of  cic- 
atricial tissue. 

TRANSPLANTATION    OF    SKIN. 

Epidermization  of  a  large  granulation  surface  is  a  slow  process,  even 
under  the  most  favorable  circumstances,  and  the  resulting  cicatrix  is  often 
large,  gives  rise  to  contraction,  and  not  infrequently  becomes  the  seat  of 
keloid  or  ulcerative  processes  subsequently.  Modern  surgery  offers  means 
by  which  this  tedious  process  can  be  materially  shortened,  and  healing  is 
accomplished  by  the  formation  of  a  more  satisfactory  scar. 

Reverdin's  Method. — In  1854  F.  H.  Hamilton  practiced  successfully 
transplantation  of  skin  in  the  treatment  of  chronic  ulcers,  and  called  the 
procedure  anaplasty.  In  1870  Eeverdin  discovered  that  small,  thin  pieces 
of  superficial  skin,  transplanted  upon  a  healthy,  granulating  surface,  formed, 
in  a  short  time,  organic  connections  with  the  granulations,  and  that  epi- 
dermization proceeded  independently  from  such  transplanted  islets  of  skin. 
Later,  Schwenninger  demonstrated,  by  his  experiments,  that  hairs  could 
similarly  be  transferred  to  a  granulating  surface.  An  open,  granulating 
M^ound  or  ulcer  can  be  covered  over  with  epidermis  in  a  short  time  by  resort- 
ing to  Eeverdin's  method  of  transplantation  of  skin.  The  most  essential 
condition  for  success  is  an  aseptic  condition  of  the  granulations.  In  sup- 
purating wounds  this  method  of  treatment  is  not  applicable  until  suppura- 
tion has  ceased  and  the  granulations  are  small  and  firm.  The  part  from 
which  the  skin  is  to  be  taken,  in  preference  the  thigh  or  arm,  should  be 
shaved  and  disinfected.  The  only  instruments  required  for  cutting  and 
transferring  the  skin  is  an  ordinary  sewing-needle  fixed  in  a  needle-holder, 
or,  what  is  still  better,  a  pair  of  hasmostatic  forceps  and  a  sharp  razor.  With 
the  needle  the  skin  is  transfixed,  and  with  a  razor  a  thin  section  the  size 
of  the  circumference  of  a  split  pea  is  removed  and  at  once  transferred  to 
the  granulating  surface  with  the  needle  in  such  a  manner  that  the  cut  sur- 
face is  brought  accurately  in  contact  with  the  granulations.  As  the  de- 
tached portion  of  the  skin  always  curls  toward  the  raw  surface  at  its  mar- 
gins, it  must  be  carefully  flattened  out  with  the  point  of  one  or  tAvo  needles, 
care  being  taken  to  imbed  it  well  among  the  granulations  without  causing 


TEANSPLANTATION    OF    SKIN.  39 

any  bleeding.  The  grafts  are  planted  in  rows,  commencing  near  the  border 
and  leaving  small  spaces  between  the  separate  grafts.  Each  row  of  grafts 
is  then  separately  protected  with  a  narrow  strip  of  protective  silk,  and  a 
thick,  antiseptic  compress  is  applied  and  retained  by  a  bandage,  which  should 
exercise  uniform  gentle  compression.  The  dressing  should  not  be  removed 
in  less  than  a  week.  At  this  time  the  grafts  will  not  only  have  become  firmly 
attached  to  the  subjacent  surface,  but  each  of  them  has  become  surrounded 
with  a  zone  of  new  epithelial  cells.  As  each  graft  now  constitutes  an  inde- 
pendent centre  of  epithelial  proliferation,  the  remaining  portion  of  the  gran- 
ulation surface  soon  becomes  paved  by  new  epithelial  cells,  and  epidermiza- 
tion  and  cicatrization  are  rapidly  completed.  The  results  obtained  by  this 
method  of  treatment  have  not  always  been  such  as  to  satisfy  the  earlier  ex- 
pectations. The  new  skin  is  but  a  poor  substitute  for  the  normal  structure. 
Epidermization  is  hastened,  and  the  results  are  better  than  after-healing 
without  skin-grafting,  but  the  ideal  result,  the  formation  of  tissue  resem- 
bling true  skin,  is  not  obtainable  by  this  method  of  skin  transplantation. 

Thiersch's  Method.^ — If  after  an  operation  or  injury  it  is  found  that  a 
too  extensive  defect  of  the  skin  renders  approximation  by  suturing  impos- 
sible, the  surgeon  has  it  now  in  his  power  to  supply  the  defect  at  once  by 
taking  large  skin-grafts  from  another  part  of  the  body,  or  from  another  per- 
son, and  planting  them  in  the  form  of  a  mosaic  upon  the  raw  surface.  This 
method  of  skin-grafting  in  the  treatment  of  extensive  superficial  Avounds, 
as  after  the  extirpation  of  a  lupus,  or  a  surface  epithelioma,  was  devised  by 
Thiersch.  Experience  has  shown  that  grafts  of  the  whole  thickness  of  the 
skin,  and  an  inch  square,  if  planted  smoothly  upon  the  raw  surface  and  kept 
uninterruptedly  in  contact  with  the  wound  by  an  appropriate  dressing,  not 
only  retain  their  vitality,  but  enter  rapidly  into  organic  connections  with  the 
part  with  which  they  have  been  brought  into  contact,  and,  at  the  same  time, 
their  anatomical  and  physiological  properties  are  maintained  to  perfection. 
Thiersch  found  that  after  eighteen  hours  they  were  supplied  with  new  blood- 
vessels, which  could  be  successfully  injected  from  the  vessels  of  the  part  to 
which  they  had  become  adherent.  This  method  of  transplantation  of  skin 
is  now  extensively  practiced  in  connection  with  plastic  operations  about  the 
face.  For  such  purposes  the  skin  is  taken  from  the  region  of  the  trochanters, 
as  the  skin  here  is  almost  or  entirely  devoid  of  hair.  All  bleeding  from  the 
Abound  to  be  covered  with  the  grafts  is  carefully  arrested  by  surface  pressure 
before  the  grafts  are  planted,  as  it  is  necessary  to  secure  accurate  coaptation 
of  the  wound-surfaces  in  order  to  secure  a  favorable  result.  The  modern 
method  of  performing  rhinoplasty  furnishes  a  good  illustration  of  this 
method  of  skin  transplantation. 

As  a  matter  of  course,  success  by  this  method  of  skin-transplantation 
can  only  be  expected  when  the  wound  and  grafts  are  aseptic,  and  the  parts 


40 


PEINCIPLES    OF    SURGEEY. 


are  kept  in  this  condition  at  least  until  vascularization  of  the  grafts  has  taken 
place.  After  the  grafts  have  been  planted  the  treatment  of  the  wound  is  the 
same  as  in  Eeverdin's  method.  During  the  after-treatment  it  is  important 
to  secure  rest  for  the  part,  and  to  prevent,  by  appropriate  means  of  fixation, 
even  the  slightest  displacement  of  the  grafts  in  any  direction.  A  good  plan 
is  to  apply  a  thin  plaster-of-Paris  bandage  over  the  dressing.  Schede  has 
substituted  Thiersch's  for  Eeverdin's  method  in  the  treatment  of  granulating 
surfaces  by  skin-grafting,  and  the  results  have  been  very  gratifying.     The 


Pig.  21.— Rhinoplasty  and  Transplantation  of  Large  Skin-grafts.  A,  A,  skin-flaps 
from  face  turned  inward  and  covered  with  large  flap  from  forehead,  C  after  C",  and  B 
after  B'.  Defects  covered  with  mosaic  of  large  skin-grafts  from  trochanteric  region. 
(Thiersch.) 


granulating  surface  is  transformed  into  a  recent  aseptic  wound  by  removing 
the  granulations  with  a  sharp  spoon.  After  all  bleeding  has  ceased  the  wound 
is  covered  with  large  skin-grafts  in  the  manner  described.  The  skin  obtained 
after  this  method  of  transplantation  presents  a  normal  appearance.  I  have 
repeatedly  seen  that,  after  excision  of  an  epithelioma  of  the  frontal  or  parietal 
region,  a  defect  the  size  of  the  palm  of  the  hand  was  healed  completely  in 
less  than  three  weeks  by  using  Thiersch's  grafts.  This  method  of  skin- 
grafting  must  be  a  welcome  resource  to  the  oculists  in  the  operative  re- 


TKANSPLANTATION    OF    SKIN.  '  41 

moval  of  tuberculous  lesions  and  malignant  affections  of  the  eyelids,  as  well 
as  in  the  treatment  of  some  forms  of  ectropion. 

Wolfe's  Method.  —  Wolfe  has  obtained  excellent  results  by  covering 
defects  of  skin  an  inch  or  more  in  diameter  with  a  single  graft  of  skin  de- 
prived of  every  vestige  of  subcutaneous  fat.  The  removal  of  the  graft  must 
be  done  with  the  utmost  care,  to  insure  the  entire  thickness  of  the  skin, 
and  equal  care  is  necessary  not  to  transfer  adipose  tissue.  If  necessary,  the 
graft  may  be  fastened  in  place  with  a  few  fine  catgut  or  horse-hair  sutures. 

Hirsohberg's  Method. — Hirschberg  has  been  successful  in  planting  large 
skin-grafts  without  depriving  them  of  the  subcutaneous  fat.  In  my  own 
hands  Wolfe's  method  has  yielded  better  results. 

Transplantation  of  Mucous  Membrane. — In  the  treatment  of  traumatic 
or  ulcerative  defects  of  accessible  mucous  membranes,  it  would  seem  that 
restoration  of  the  defect  by  transplantation  of  grafts  of  mucous  membrane, 
if  found  feasible,  would  be  the  ideal  treatment.  The  first  attempt  at  trans- 
plantation of  mucous  membrane  was  conducted  by  Czerny,  in  1871.  From 
1873  to  1888  it  found  practical  application,  but  exclusively  in  ophthalmic 
surgery.  Wolfler  has  recently  shown  that  such  a  method  of  treatment  is  not 
only  practicable,  but  has  resorted  to  it  successfully  in  the  treatment  of  ob- 
stinate strictures  of  the  urethra.  After  excision  of  the  cicatrix  at  the  seat  of 
resection  he  sutured  a  circular  graft  of  mucous  membrane  to  each  end  of  the 
resected  urethra,  and  had  the  satisfaction  to  observe  that  the  graft  not  only 
retained  its  vitality,  but  became  adherent  and  constituted  an  essential  part 
of  the  new  portion  of  the  urethra.  Wolfe  has  also  succeeded  in  transplanting 
the  whole  of  the  tissues  of  the  conjunctiva  of  the  rabbit  on  to  that  of  man, 
in  order  to  fill  a  defect  caused  by  cicatricial  contraction.  Djatschenko,  in 
1890,  studied  this  subject  experimentally,  and  elucidated  the  histological 
process.  He  experimented  on  dogs,  taking  mucous  membrane  from  the 
mouth  and  inserting  it  in  defects  made  by  excising  portions  of  the  con- 
junctiva. He  found  complete  union  toward  the  ninth  day,  no  real  cicatricial 
tissue  forming.  He  places  great  stress  on  rendering  the  graft  bloodless  and 
washing  it  in  a  warm  6-per-cent.  solution  of  salt  before  it  is  implanted.  While 
the  graft  should  be  freed  of  all  fat-tissue,  care  should  be  taken  not  to  deprive 
it  of  its  submucous  cellular  tissue,  as  otherwise  the  conditions  for  the  rees- 
tablishment  of  the  circulation  in  the  transplanted  piece  are  less  favorable. 
Another*  important  rule  laid  down  is  to  cut  the  graft  sufficiently  large  to 
cover  the  entire  defect,  as  the  uncovered  portion  forms  a  scar.  This  method 
of  dealing  with  large  defects  of  mucous  surfaces  accessible  to  direct  treat- 
ment holds  out  many  inducements  for  future  imitation.  The  difficulties  in 
the  way  of  equal  uniform  success  in  the  transplantation  of  grafts  of  mucous 
membrane,  as  in  skin-transplantation,  are  owed  to  the  location  of  the  seat 
of  operation.    In  the  former  instance  it  must  always  be  such  as  to  preclude 

3a 


42  PEINCIPLES    OF    SUEGERY. 

the  possibility  of  securing  perfect  asepsis,  on  the  one  hand,  and  the  impos- 
sibility of  applying  an  efficient  protective  dressing;  at  the  same  time,  it  is 
also  more  difficnlt  to  obtain  the  proper  material  for  the  grafting. 

CONNECTIVE    TISSUE. 

The  granulations  seen  upon  a  wound  or  ulcerating  surface  are  formed 
almost  exclusively  by  the  transformation  of  mature  connective  tissue  into 
embryonal  tissue,  the  cellular  elements  of  which  they  are  composed  being 
embryonal  connective-tissue  cells.  This  transition  of  mature  into  embryonal 
cells  is  accomplished  by  karyokinesis.  As  connective  tissue  is  found  almost 
in  every  part  and  organ  of  the  body,  it  takes  an  active  part  in  the  repair  of 
all  wounds,  and,  when  the  more  important  tissues  in  the  wound  cannot  be 
approximated  for  organic  union  to  take  place,  its  greater  vegetative  capacity 
enables  it  to  produce  a  large  amount  of  new  material,  which  later  forms  a 
connecting  bridge  of  cicatricial  tissue.  For  instance,  in  a  transverse  wound 
of  a  muscle,  where  it  is  often  difficult,  if  not  impossible,  to  keep  the  divided 
ends  sufficiently  approximated  for  the  wound  to  heal  by  the  interposition 
of  new  muscle-cells,  the  gap  is  spanned  by  a  band  of  connective  tissue,  which, 
if  not  completely,  at  least  partially,  restores  the  function  of  the  muscle 
by  furnishing  it  with  two  additional  fixed  points  of  attachment.  G-raser  has 
shown  that  the  first  karyokinetic  changes  are  seen  in  connective-tissue  cells 
some  distance  from  the  surface  of  the  wound,  and  that  the  new  cells  reach 
the  surface  with  the  new  blood-vessels,  where  they  constitute  the  granula- 
tion-tissue. In  aseptic  wounds,  where  cicatrization  progresses  rapidly,  the 
embryonal  connective-tissue  cells,  or  granulation-cells,  are  short  lived,  as 
they  are  rapidly  transformed  into  mature  connective  tissue,  which  here  con- 
stitutes the  cicatrix.  In  suppurating  wounds  the  superficial  layer  of  em- 
bryonal cells  is  brought  in  contact  with  the  pus-microbes  and  their  toxins, 
which  destroy  the  protoplasm  of  the  cells,  when  they  are  transformed  into 
pus-corpuscles,  while  those  nearer  the  blood-vessels  retain  their  vitality  and 
capacity  of  undergoing  cicatrization. 

BLOOD-VESSELS. 

"Wounds  of  large  blood-vessels,  with  few  exceptions,  require  such  meas- 
ures in  their  treatment  which  completely  arrest  the  circulation  and  which 
aim  at  permanent  obliteration  of  the  lumen  by  the  usual  method  of  cell- 
proliferation  and  cicatrization.  A  wound  of  an  artery,  if  accessible  to  direct 
treatment,  should  be  treated  by  cutting  the  vessel  completely  across  and 
applying  a  ligature  to  each  end.  A  small  wound  of  a  large  vein  can  be  treated 
successfully,  under  favorable  conditions,  by  closing  it  with  a  lateral  ligature. 
With  a  tenaculum  the  margins  of  the  wound  are  transfixed,  and,  by  making 


BLOOD-VESSELS. 


43 


slight  traction,  the  vein-wall  is  raised,  and  around  the  base  of  the  little  cone 
thus  formed  a  tine  catgut  ligature  is  applied.  If  the  wound  remains  aseptic, 
the  mural  thrombosis  at  the  seat  of  ligation  is  slight,  and  the  closure  of  the 
wound  is  effected  without  obliteration  of  the  lumen  of  the  vessel.  Larger 
vein  wounds  have  been  successfully  treated  by  suturing  with  fine  catgut. 
The  sutures  are  inserted  in  the  same  manner  as  Lembert's  suture  in  closing 
a  wound  of  the  intestine.  A  wound  of  a  blood-vessel  usually  terminates, 
spontaneously  or  through  the  intervention  of  art,  in  permanent  interruption 
of  the  circulation  by  the  formation  of  an  intravascular  cicatrix.    For  many 


Vasa  vasonim. 


Intima. 


Partly-formed  connective 
tissue  from  erdothelia. 


Proliferated 
connective 
tissue  in 
lumen. 


Fig.  22. — Microscopical  Appearances  of  the  Interior  of  Artery  of  Dog  Forty-nine  Days 
after  Ligation.     Transverse  Section  through  Border  of  Artery.     X  240. 

years  it  has  been  maintained  that  obliteration  of  a  vessel  after  injury,  dis- 
ease, or  ligature  resulted  from  what  was  termed  "organization  of  the  throm- 
bus." It  was  believed  that  the  thrombus  became  vascular  either  from  the 
lumen  of  the  vessel  or  the  vasa  vasorum,  and  that  the  histological  elements 
in  the  thrombus  took  an  active  part  in  the  production  of  the  intravascular 
cicatrix.  Numerous  experimental  investigations  by  different  authors,  un- 
dertaken for  the  purpose  of  demonstrating  that  in  wounds  of  blood-vessels 
healing  takes  place  in  the  same  manner  as  in  the  wounds  of  other  tissues, 
have  shown  that  the  blood-clot  always  occupies  only  a  passive  role,  and,  if 
present,  is  only  in  the  way  of  a  speedy,  definitive  closure,  which  invariably  is 


44 


PRINCIPLES    OF    SUEGERY. 


effected  by  proliferation  from  the  fixed  cells  of  the  vessel-wall.  Eliminating 
the  thrombus  as  an  active  agent  in  the  obliterating  process,  we  can  say  that 
union  between  the  tissues  which  are  brought  in  contact  by  the  ligature  takes 
place  by  tissue-proliferation  from  the  walls  of  the  vessel  itself.  In  the  true 
sense  of  the  word,  direct  or  immediate  imion  is  as  impossible  here  as  in  any 
other  wound,  and,  like  everywhere  else,  the  intravascular  cicatrix  is  formed 
from  tissue  derived  from  the  tissue  of  the  injured  vessel-wall.  In  case  the 
inner  tunics  are  severed  by  the  ligature,  the  lacerated  surfaces  are  brought  in 
contact  with  the  adventitia,  and  repair  takes  place  as  in  other  tissues  which 
are  largely  composed  of  connective  tissue,  the  process  extending  from  both 


Young 
connective- 
tissue 
cells. 


Endothelial 
proliferation. 


Proliferation 
of  connective 
tissue. 


Fig. 


23. — Microscopical  Appearances  of  the  Interior  of  Vein  of  Dog  Forty-nine  Days  after 
Ligation.    Transverse  Section  of  Part  of  Vein  in  Ligated  Portion.     X  240. 


sides  of  the  ligature,  where  endothelia  assist  in  the  process  of  cicatrization. 
If,  on  the  other  hand,  the  continuity  of  the  vessel  is  not  destroyed  by  the 
ligature,  and  the  intima  is  simply  brought  in  contact  without  being  ruptured, 
the  new  cells  from  the  connective  tissue  perforate  the  endothelial  lining,  and 
the  new  elements  of  the  latter  join  in  the  reparative  process  by  being  con- 
verted from  their  embryonal  state  into  connective  tissue.  The  histological 
changes  in  the  interior  of  veins  undergoing  obliteration  are  the  same  as  in 
arteries,  the  new  material  of  which  the  cicatrix  is  composed  being  derived 
exclusively  from  the  endothelial  and  connective-tissue  cells. 

J.  Collins  Warren,  who  has  done  excellent  work  in  studying  experiment- 


BLOOD-VESSELS.  45 

ally  the  healing  of  arteries  after  ligature,  maintains  that  he  has  seen  suffi- 
cient evidence  in  his  specimens  that  the  muscle-cells  in  the  tunica  media 
take  an  active  part  in  the  process  of  repair.  The  same  author  compares  the 
process  of  healing  in  arteries  to  the  formation  of  callus  after  fracture,  and 
hence  calls  the  intravascular  material  the  internal  and  the  extravascular  the 
external  callus.  Ballance  and  Edmunds,  in  their  classical  work,  "Ligation 
in  Continuity,"  have  given  the  profession  the  most  reliable  and  exhaustive 
treatise  on  this  subject.  The  numerous  experiments  of  the  author  on  ligation 
of  arteries  and  veins  have  demonstrated,  to  his  own  satisfaction,  that  the 
most  speedy  obliteration  of  a  vessel  is  obtained  if  the  vessel  is  rendered  blood- 
less by  the  application  of  two  ligatures.  The  ligatures  are  applied  with  suffi- 
cient firmness  to  obliterate  the  lumen  of  the  vessel  ivithout  rupturing  any 
of  its  coats.  After  ligation  the  walls  of  the  vessel  became  thickened;  so  that, 
a  few  weeks  after  the  ligatures  had  been  applied,  the  vessel  presented  a 
spindle  shape,  tapering  toward  each  side,  a  condition  entirely  due  to  the 
formation  of  new  material:   the  external  callus  of  Warren.     The  bloodless 


Fig.  24.— Femoral  Artery  of  Dog  Fifty  Days  after  Double  Ligation  with  Silk.  Be- 
low, Transverse  Section  showing  Bloodless  Space  Filled  with  Cicatricial  Material.  (Nat- 
ural size.) 

space  between  the  ligatures  is  obliterated  in  a  short  time  by  cells  which  enter 
it  from  the  vessel-wall. 

In  the  obliteration  of  veins  and  ligation  of  arteries  in  their  continuity, 
the  double  ligature,  including  a  bloodless  space  about  ^/a  inch  in  length, 
places  the  tissues  in  the  most  favorable  conditions  for  speedy,  definitive 
closure  by  an  intravascular  cicatrix.  When  the  vessel  is  exposed  catgut 
should  be  used,  but  in  the  subcutaneous  ligation  of  veins  silk  is  preferable. 
Since  the  introduction  of  antiseptic  surgery  and  the  aseptic  ligature,  sec- 
ondary haemorrhage  has  become  an  exceedingly  rare  accident,  and,  when  it 
does  occur,  it  is  in  wounds  where  the  antiseptic  measures  have  failed.  A 
vessel  in  an  aseptic  wound,  tied  with  an  aseptic  ligature,  becomes,  in  a  few 
hours,  the  seat  of  a  regenerative  process  which  effectually  guards  against 
the  possibility  of  hsemorrhage,  even  if  the  mechanical  obstruction  caused 
by  the  ligature  should  be  removed  after  a  few  days.  The  aseptic  ligature, 
applied  under  strict  antiseptic  precautions,  has  been  advantageous  in  other 
directions.  The  older  surgeons  always  expected,  after  ligating  an  artery  in 
its  continuity,  that  the  thrombus  would  extend  on  the  proximal  side  to  the 


46 


PEINCIPLES    OF    SUEGERY. 


nearest  collateral  branch,  and,  on  this  account,  they  were  ahvays  anxious  to 
secure  a  space  of  an  inch  or  more  between  the  ligature  and  the  nearest  large 
collateral  branch,  in  order  to  prevent  secondary  hsemorrhage.  The  aseptic 
ligature  is  never  followed  by  such  extensive  thrombosis,  and  the  intravas- 
cular cicatrix  is  often  exceedingly  narrow, — in  fact,  almost  linear.  The  lim- 
ited thrombosis  and  the  prompt  formation  of  an  intravascular  cicatrix  place 
the  surgeon  now  in  a  position  that  he  can  ligate  a  large  artery,  close  to  a 
collateral  branch  or  near  a  point  of  bifurcation,  without  a  particle  of  fear  of 
incurring  secondary  haemorrhage.    In  the  ligation  of  veins  the  aseptic  liga- 


Fig.  25. — Collateral  Circulation  Bight  Months  after  Ligation  of  the  Aorta  in  a  Dog. 

(Luigi  Porta.) 

ture  has  dispersed  all  fear  of  suppurative  thrombophlebitis  and  pygemia:  com- 
plications which  were  formerly  so  much  feared,  even  after  insignificant  op- 
erations on  veins.  In  the  repair  of  wounds  union  between  the  divided  ends 
of  blood-vessels  is  probably  never  effected.  The  vessel-ends  are  temporarily 
closed  either  by  tying  with  a  ligature  or  by  the  formation  of  a  thrombus,  the 
former  being  the  case  when  vessels  of  some  size  have  been  divided,  the  latter 
being  accomplished  usually  spontaneously  in  vessels  which  give  rise  to 
parenchymatous  haemorrhage.  In  either  instance  the  ends  of  the  vessel  are, 
later,  permanently  sealed  by  the  formation  of  a  cicatrix  by  proliferation  of 
fixed  tissue-cells,  the  endothelia,  and  connective-tissue  cells.  The  inter- 
rupted circulation  between  the  two  sides  of  the  wound  is  restored  indirectly 


MUSCLES.  47 

through  collateral  branches,  which  are  always  new  blood-vessels.  The  angio- 
blasts  in  the  injured  capillary  vessels  assume  active  tissue-proliferation  within 
twenty-four  hours  after  the  injury  has  occurred,  and  through  them,  almost 
exclusively,  the  new  blood-vessels  are  formed,  in  the  shape  of  loops,  which, 
coming,  as  they  do,  from  both  sides,  establish  the  vascular  connection  be- 
tween the  two  surfaces  of  the  wound.  (See  Fig.  25.)  Many  of  these  new 
blood-vessels  disappear '  after  the  consummation  of  the  reparative  process, 
while  others  remain  as  permanent  collateral  vessels  between  the  closed  ends 
of  the  old  blood-vessels  permanently  separated  by  the  injury. 

MUSCLES. 

It  is  only  quite  recently  that  it  has  been  ascertained  that  a  divided  mus- 
cle can  unite,  under  favorable  circumstances,  by  interposition  of  new  mus- 
cular tissue  between  the  divided  ends.  It  was  formerly  believed  that  healing 
was  always  accomplished  by  the  formation  of  connective  tissue,  and  that  the 
ends  of  the  cut  muscle  remained  permanently  separated  by  a  bridge  of  cic- 
atricial tissue.  The  theory  that  connective  tissue  can  be  transformed  into 
muscular  tissue  is  untenable,  since  Pflueger  has  demonstrated  the  minute 
striicture  of  muscular  fibre.  Kolliker  has  shown  that  the  fibrillse  in  the  mus- 
cle-fibre constitute  the  real  ground-substance.  Eabl  ascertained,  by  his  em- 
bryological  researches,  that  the  muscular  tissue  is  derived  from  a  distinct 
portion  of  the  mesoblast,  and,  consequently,  proved  that,  at  a  very  early 
period  of  embryonal  life,  an  absolute  difference  takes  place  between  mus- 
cular and  connective  tissue.  Heterotopic  muscular  structures  must,  there- 
fore, be  looked  upon  not  as  products  of  connective-tissue  proliferation,  but 
as  a  growth  from  a  displaced  embryonal  matrix  of  muscular  tissue. 

The  vegetative  capacity  of  muscle-cells,  striped  and  unstriped,  is  quite 
limited,  as  compared  with  some  of  the  other  tissues;  so  that,  if  the  ends  of 
a  muscle  that  has  been  cut  transversely  are  separated  for  more  than  an  inch, 
complete  restoration  of  the  continuity  of  the  muscle  is  not  attained,  and  the 
two  ends  are  connected  by  a  band  of  connective  tissue.  If,  during  the  heal- 
ing of  the  wound,  the  cut  surfaces  of  the  muscle  are  kept  in  accurate  contact, 
and  even  if  a  gap  of  half  an  inch  exist  between  them,  restoration  ad  integrum 
takes  place  by  proliferation  of  the  muscle-elements  near  the  seat  of  injury. 

Non-striated  Muscular  Fibre, — Stilling  and  Pfitzner,  as  well  as  Busachi, 
have  shown  that  unstriped  muscular  fibres  multiply  by  indirect  division  of 
their  nuclei,  and,  in  the  repair  of  wounds  of  this  tissue,  new  fibres  are  pro- 
duced exclusively  by  this  method.  These  authors  studied  the  karyokinetic 
changes  in  the  muscular  fibres  of  the  Triton  tceniatus.  They  observed,  after 
the  division  of  the  nucleus  in  the  usual  manner  by  karyokinesis,  that  as  the 
new  nuclei  separated  and  approached  the  poles  of  the  cell  the  protoplasm 


48  PEINCIPLES    OP    SUKGEEY. 

of  the  cell-body  at  the  transverse  axis  became  narrower,  showing  a  well- 
marked  constriction,  which  would  indicate  that  subseqnentl}^  cell-division 
occurred.  Herczel  witnessed  similar  changes  in  the  hypertrophic  muscular 
coat  of  the  intestines  on  the  proximal  side  of  strictures.  In  defects  caused 
by  the  injury,  removal,  or  destruction  of  unstriped  muscular  fibres,  regen- 
eration takes  place  only  from  the  margins,  while  the  centre  at  first  is  oc- 
cupied by  connective  tissue.  The  new  muscular  fibres  are  at  first  irregularly 
arranged,  and  it  is  only  toward  the  completion  of  the  healing  process  that 
the  new  tissue  represents  to  perfection  the  mature  muscular  fibres.  Klebs 
is  of  the  opinion  that  the  leucocytes  serve  as  food  for  the  cells  which  undergo 
karyokinetic  changes. 

Striated  Muscular  Fibre. — 0.  Weber,  as  early  as  1854,  claimed  that  in 
the  healing  of  wounds  new  muscular  fibres  are  produced,  but,  in  accordance 
with  the  views  which  then  prevailed,  believed  they  were  derived  from  con- 
nective tissue.  Wittich  saw,  in  hibernating  frogs,  new  fibres  which  he  be- 
lieved had  developed  from  the  cells  of  the  internal  perimysium.  In  1865, 
after  an  examination  of  a  genuine  myoma  striocellulare.  Buhl  expressed  the 
opinion  that  new  muscular  fibres  are  produced  from  old  fibres.  In  the  same 
year  Waldeyer  discovered  the  muscle-cell  sheath,  and  he  regarded  the  cell 
inclosed  by  it  as  a  derivative  of  the  nucleus  of  the  fibre,  but,  with  Zenker 
and  others,  he  still  regarded  the  perimysium  as  the  source  of  new  muscular 
fibres.  In  1868  E.  Neumann  made  the  observation  that  after  section  or 
laceration  of  a  muscle  the  ends  of  the  fibres  became  the  seat  of  active  tissue- 
changes,  which  resulted  in  the  formation  of  what  he  termed  muscle-buds. 
These  muscle-buds  were  not  only  found  at  the  ends  of  the  fibres,  but  also 
on  their  sides;  at  first  they  were  seen  to  be  composed  of  numerous  nuclei  and 
protoplasm,  while  later  they  were  transformed  into  striated  fibres.  The  sar- 
colemma  is  such  a  delicate  structure  that  new  cells  which  form  within  it 
readily  find  their  way  through  it,  and  appear  upon  its  outer  surface  in  the 
shape  of  buds,  as  described  by  Neumann. 

Tizzoni  has  recently  investigated  the  karyokinetic  changes  in  the  nuclei 
or  sarcoblasts  in  the  perimysium  during  the  repair  of  muscle  wounds.  The 
first  evidences  of  cell-proliferation  were  seen  in  the  nuclei  or  myoblasts 
nearest  the  seat  of  injury,  and  proliferation  took  place  in  fibres  which  had 
undergone  degeneration  as  well  as  in  those  which  presented  a  striated  ap- 
pearance. Leven  found,  during  the  first  twenty-four  hours  after  injury,  an 
increase  of  nuclei  of  the  sarcolemma-sheath.  These  new  neuclei  are  arranged 
in  the  form  of  rows  and  heaps,  and  by  mutual  pressure  are  flattened.  Many 
of  these  new  elements  present  karyokinetic  figures,  and  aroimd  them  proto- 
plasm is  deposited,  and  the  new  cells  become  spindle-shaped.  The  new  cells 
increase  in  number  from  the  third  to  the  fourth  day,  so  that  at  this  time  from 
five  to  six  can  be  seen  under  one  field.    Klebs  studied  regeneration  of  mus- 


MUSCLES. 


49 


cle  in  young  guinea-pigs  after  puncturing  subciitaneously  the  gastrocnemius 
muscle.  He  came  to  the  following  conclusions:  A  portion  of  the  muscular 
fibres  die  and  shrink,  and  in  this  condition  they  can  be  stained  more  deeply 
with  hsematoxylin  than  the  others.  Such  fibres  are  completely  removed  by 
absorption  within  the  first  four  days.  In  the  fibres  which  remain  striated 
the  fibrillse  become  plainer,  and  in  them  the  regenerative  process  can  be  dis- 
tinctly seen.  The  nuclei  increase  in  number,  and  are  packed  densely  to- 
gether, but  at  this  stage  he  was  unable  to  detect  any  evidence  of  karyokinesis. 
During  this  stage  Steudel  was  also  unable  to  detect  any  appearances  which 
indicated  indirect  cell-division.  These  young  cells  are  called  sarcoblasts  by 
Klebs,  and  their  transformation  into  muscle-fibres  is  effected  by  aggregation 


Fig.  26.— Muscular  Fibres  Near  a  Wound  in  a  State  of  Proliferation.  A,  contused 
end  of  muscular  fibre;  B,  muscular  fibre  retracted  within  sarcolemma,  the  latter  ter- 
minating in  a  sharp  point;  C,  old  fibre  degenerated  into  a  colloid  mass;  D,  young  nuclei 
between  and  upon  fibres;  E,  nuclei  surrounded  by  cell-protoplasm;  F,  new  cell,  show- 
ing striations;    G,  new  muscular  fibre.     (0.  Weher.) 


around  them  of  a  very  thin  layer  of  protoplasm.  The  youngest  cells  are  round, 
and  the  change  into  spindle  form  is  gradual.  The  new  cells  are  arranged  in 
rows  between  the  old  muscular  fibre  (Fig.  26,  between  G  and  B).  Some  au- 
thors believe  that  the  sarcoblasts  unite  end  to  end,  and  that  the  muscular 
fibre  is  formed  in  this  manner.  Kraske  and  Klebs  maintained  that  muscular 
fibres  result  from  a  single  cell  by  gradual  elongation  of  the  cell-body.  In 
the  regeneration  of  the  muscular  fibres  of  the  heart  after  injury,  Martinti  and 
Bonome  witnessed  karyomitotic  changes  in  the  interior  of  the  sheath  of 
numerous  fibres,  while  in  others  where  degenerative  changes  had  taken  place 
no  such  changes  could  be  seen.  In  wounds  of  the  heart  of  old  rats  karyo- 
mitosis  commences  five  to  six  days  after  the  injury,  and  does  not  last  longer 
than  six  to  seven  days,  and  results  only  in  incomplete  regeneration.    In  myo- 


50 


PRINCIPLES    OF    SURGERY. 


carditis  the  formation  of  new  muscular  fibres  has  been  observed  by  Yirchow, 
Boettcher,  and  Waldeyer. 

Muscle-suture. — In  the  treatment  of  recent  wonnds  special  pains  should 
be  taken  to  secure  accurate  approximation  between  the  ends  of  divided  mus- 
cles. For  this  purpose  special  means  must  be  employed  when  large  muscles 
have  been  divided  transversely.  In  such  cases  the  retraction  which  follows 
gives  rise  to  great  separation,  which  can  only  be  overcome  by  suturing  re- 
spective ends  separately  with  buried  animal  sutures.  Great  care  is  necessary 
not  to  invert  the  margins,  but  to  unite  the  cut  surfaces  throughout,  using 
for  this  purpose,  if  necessary,  as  many  as  six  sutures,  which  must  include 
considerable  tissue  in  order  to  prevent  their  tearing  through.  The  muscle- 
ends  should  be  secured  with  a  mattress-suture  of  chromicized  catgut  as  shown 
in  Fig.  27,  and  the  edges  carefully  coaptated  with  three  or  more  points  of 


Fig.  27. — Muscle-suture. 

suture  of  the  same  material.  In  muscles  supplied  with  a  well-marked  sheath 
this  should  be  sutured  separately.  In  the  after-treatment  it  is  necessary  to 
place  the  limb  in  such  a  position  that  will  relax  the  sutured  muscles,  and  to 
secure  immobility  of  the  limb  in  this  position  by  a  proper  mechanical  sup- 
port, which  should  not  be  removed  until  the  healing  process  is  completed, 
in  order  to  prevent  subsequent  diastasis  between  the  sutured  ends.  When  it 
is  desirable  to  elongate  a  contracted  muscle  in  the  correction  of  deformities, 
as  in  the  treatment  of  torticollis,  the  contracted  muscle  should  be  exposed 
by  incision,  and  after  section  a  suture  a  distance  is  applied.  A  number  of 
heavy  catgut  sutures  will  answer  an  excellent  purpose,  as  they  will  maintain 
fixation  of  the  separated  ends  in  a  desirable  position,  and  will  furnish  an 
admirable  scaffolding  for  the  new  connective-tissue  cells,  which,  later  on, 
are  transformed  into  a  tendon  which  permanently  connects  the  retracted 
ends  of  the  divided  muscle. 


MUSCLES. 


51 


Tenorrhaphy.  —  The  operation  of  suturing  a  tendon  is  called  tenor- 
rhapliy.  The  histological  processes  in  the  regeneration  of  a  tendon  are  the 
same  as  in  the  repair  of  connective  tissue.  Tendons  are  composed  of  com- 
pact connective  tissue  surrounded  by  a  delicate  membrane:    the  tendon- 


Pig.  28. — Tenorrhaphy,    a,  mattress-suture;    6,  c,  after  Wolfler;    d,  e,  paratendinous 
suture,  after  Hueter.     (Esmarch.) 

sheath.  In  injuries  of  tendons  the  fibroblasts  furnish  the  new  material^ 
which  is  interposed  between  the  cut  or  torn  ends  and  which  restores  the  con- 
tinuity of  the  tendon.  The  process  of  repair  is  instituted  near  the  tendon- 
ends  and  shows  itself  in  the  splitting  up  of  the  fibrils.    The  new  material  acts 


Fig.  29.— Tendoplasty.     a,  after  Madelung;    &,  after  TiUaux;    c,  after  Hueter; 
d,  after  Gluck.     (Esmarch.) 


first  the  part  of  a  cement-substance,  but  in  the  course  of  two  or  three  weeks 
is  transformed  into  new  connective  tissue.  In  open  wounds,  complicated 
by  injury  to  tendons,  the  careful  surgeon  never  neglects  to  place  the  tendon- 
ends  in  the  most  favorable  conditions  for  speedy  and  satisfactory  repair  by 


52 


PKINCIPLES    OF    SUEGEEY. 


resorting  to  primar}'  tendon-suture.  If  a  number  of  tendons  have  been  in- 
jured at  the  same  time,  it  is  often  difficult  to  identify  the  ends  which  belong 
together  and  much  time  is  often  consumed,  and  a  great  deal  of  care  must  be 
exercised  in  finding  and  suturing  the  respective  ends.  If  the  proximal  end 
has  retracted  into  the  sheath  beyond  easy  reach  it  is  better  to  lay  the  sheath 
open  than  to  make  repeated  fruitless  attempts  to  grasp  the  tendon.  The  best 
suturing  material  is  chromicized  catgut.  The  technique  of  tenorrhaphy  is 
well  shown  in  Fig.  28.   ' 

The  surgeon  is  often  called  upon  to  restore  the  continuity  of  a  tendon 


Fig.  30.— Secondary  Suturing  of  Extensor  Tendons  of  Fingers  by  the 
suture  a  distance.    (E.  J.  Senn.) 


in  cases  in  which  primary  tendon-suture  was  neglected  or  in  which  it  failed, 
and  then  resorts  to  secondary  tenorrhaphy,  which  is  performed  in  the  same 
manner  as  primary  tendon-suture,  after  the  tendon-ends  have  been  exposed 
and  vivified. 

Tendoplasty. — In  cases  in  which  the  loss  of  substance  in  tendon  injuries 
renders  approximation  of  the  tendon-ends  impossible,  and  in  many  cases  of 
open  tenotomies  for  contractured  tendons,  restoration  of  the  continuity  of 
the  tendon  can  only  be  secured  by  a  plastic  operation,  which  in  this  instance 


MUSCLES. 


53 


is  called  tendoplasty.    A  number  of  valuable  procedures  are  shown  in  Fig. 
39. 

Gluck  interposes  between  the  ends  of  the  tendon  a  braided  bundle  of 
catgut,  which  acts  as  a  temporary  bridge-work  for  the  fibroblasts  and  which 
is  replaced,  in  the  course  of  time,  by  permanent  tissue.  E.  J.  Senn  employed 
this  method  of  suturing;  a  distance,  with  2:reat  success  in  a  case  of  extensive 


1. — Tendon-elongations. 


loss  of  tendon-tissue  involving  all  of  the  extensor  tendons  of  the  fingers  of 
one  hand.  The  degree  of  separation  of  the  tendon-ends  and  technique  of 
operation  are  shown  in  Fig.  30.  The  patient  recovered  full  use  of  the  ex- 
tensor tendons  in  the  course  of  two  months. 

An  exceedingly  valuable  method  of  effecting  elongation  of  a  contract- 
ured  tendon  was  devised  by  Anderson.  It  consists  in  splitting  the  tendon 
longitudinally  and  cutting  each  half  on  opposite  sides  sufficiently  far  apart 


54  PEiNCirLES  or  surgery. 

so  that  tlie  necessary  degree  of  elongation  can  be  secured  by  suturing  to- 
gether, end  to  end  or  laterally,  the  long  ends.  (Fig.  31.)  In  uniting  a  large 
tendon,  either  by  simple  suturing  or  by  a  plastic  operation,  it  is  important 
to  suture  the  sheath  separately;  or,  if  this  is  absent,  to  make  a  new  sheath 
of  connective  tissue  with  which  the  tendon  should  be  covered.  Immobiliza- 
tion of  the  limb  must  be  continued  until  the  process  of  repair  is  completed, 
which  will  require  from  three  to  six  M'eeks. 

BONE. 

The  granulation  material  by  which  the  fractured  bone  unites  is  called 
callus.  According  to  the  location  of  this  material  around,  within,  or  between 
the  fragments,  we  speak  of  an  external,  internal,  or  intermediate  callus. 
The  external,  or  provisional,  callus  is  abundant,  as  a  rule,  where  the  broken 
bone  is  surrounded  by  a  thick  cushion  of  soft  parts,  and  when  the  fragments 
are  not  well  immobilized.  It  forms  early  and  disappears  gradually  after  the 
fracture  has  united.  The  internal,  or  medullary,  callus,  which  takes  the 
place  of  the  medullary  tissue  in  fractures  of  the  shaft  of  the.  long  bones, 
serves  a  useful  purpose  as  a  means  of  fixation  of  the  fragments,  and  is  also 
removed  in  the  course  of  time  after  union  has  taken  place,  and  with  its  dis- 
appearance the  medullary  cavity  is  restored.  The  intermediate,  or  definitive, 
callus  is  the  material  interposed  between  the  broken  surfaces,  and  which  is 
transformed  into  permanent  tissue.  Callus  is  the  product  of  cell-prolifera- 
tion of  those  tissue-elements  which  are  directly  concerned  in  the  growth  and 
development  of  bone. 

Duhamel  de  Monceau  attributed  to  the  periosteum  and  endosteum  the 
function  of  producing  callus.  Haller  and  his  prosector,  Detlef,  believed  that 
the  periosteum  takes  no  part  in  the  regeneration  of  bone,  but  that  callus  is 
derived  from  the  fractured  ends  of  the  bone,  more  especially  the  myeloid  tis- 
sue. Dupuytren  maintained  that  the  periosteum  and  the  paraperiosteal  con- 
nective tissue  were  bone-producing  tissues.  Cruveilhier  claimed  that  the  , 
lacerated  soft  tissues  around  the  fractured  bone-ends,  the  jDcriosteum,  con- 
nective tissue,  muscles,  tendons,  etc.,  furnished  the  material  for  the  callus. 

Flourens  claimed  that  the  periosteum  alone  could  produce  new  bone. 
Rokitansky  asserted  that  callus  is  developed  directly  from  bone  and  its  con- 
nective tissue,  including  the  periosteum.  From  his  own  experimental  work, 
R.  Heine  came  to  the  conclusion  that  regeneration  of  bone  takes  place  from 
connective  tissue  in  and  around  bone  and  the  periosteum.  According  to 
Virchow,  callus  is  produced  from  connective  tissue  outside  of  the  bone,  as 
well  as  from  the  medullary  tissue.  Hofmokl  considered  as  sources  of  callous 
formation  the  periosteum,  bone,  and  marrow.  Gegenbauer  takes  the  ground 
that  bone  is  produced  directly  from  connective  tissue.     He  asserts  that 


BONE. 


55 


Sharpey's  fibres,  if  traced  carefully,  can  be  seen  springing  from  a  bony  point 
between  the  Haversian  canals,  from  which  point  they  radiate  toward  both 
sides  into  the  lamellar  systems.  The  fibres  form  net-works,  and  -at  points 
of  intersection  bone-cells  are  produced,  and  a  deposit  of  lamellse  takes  place 
aronnd  the  connective-tissue  fibres. 

It  is  now  generally  conceded  that  the  provisional  callus  is  the  product 
of  tissue-proliferation  from  the  periosteum,  while  the  definitive,  or  perma- 
nent, callus  is  produced  directly  from  the  medullary  tissue.    The  provisional 


'11 '"   1  A^M' 


Fig.  32.— Section  through  Callus  Fifty-two  Hours  after  Fracture  of  Ulna  from 
Rabbit.  Beginning  Formation  of  Osteoid  Tissue.  A,  cortical  portion  of  bone;  B,  osteoid 
tissue;  O,  beginning  of  formation  of  a  lamella,  surrounded  by  osteoblasts;  D,  perios- 
teum.    (Hartnack,  obj.  8.)     (.Bajardi.) 

callus  is  Nature's  splint,  its  only  object  being  to  immobilize  the  parts  until 
the  definitive  callus  firmly  and  permanently  unites  the  fragments.  The 
temporary  callus  is  an  accidental  product,  and  appears  earliest  and  most 
copiously  where  the  paraperiosteal  tissues  are  most  abundant  and  motion  be- 
tween the  fragments  greatest;  the  intermediate  or  permanent  callus  is  pro- 
duced later,  and  is  transformed  into  permanent  tissue.  Oilier  and  Bucholtz, 
in  their  experiments  on  transplantation  of  periosteum,  found  that  the  trans- 
planted tissue  first  produced  cartilage,  which  later  was  transformed  into 


56 


PEINCIPLES    OF    SUEGERY. 


bone;  but  they  also  ascertained  that  such  bone  disappeared  again  unless  it 
formed  in  a  place  where  bone  normally  exists.  Cohnheim  and  Maas  came  to 
the  sama  conclusion  from  their  experiments  on  intravenous  transplantation 
of  periosteal  graft.  It  is  possible  that  special  cells  (Mastzellen)  are  the  active 
agents  in  the  removal  of  tissue  in  places  where  it  has  no  physiological  exist- 
ence. Macewen  has  maintained  for  years  that  bone  grows  only  from  bone,' 
and  the  results  obtained  by  applying  this  principle  in  practice  speaks  strongly 
in  favor  of  this  supposition.  That  medullary  tissue  alone  can  produce  bone 
has  been  experimentally  demonstrated  by  Bruns.     The  osteoblasts  from 

R         jH 

-    '-     ■  —  p 

Fig.  33.— Transverse  Section  through  Callus  of  Tibia  of  Rabbit  Forty  Days  after 
Fracture,  with  External  Resorption.  P,  periosteum,  much  thickened;  R,  giant  cells  or 
osteoclasts;  Q,  blood-vessels;  M,  medullary  resorption-spaces;  K,  compact  portion  of 
bone.     {MO'O'S.^ 

which  bone-production  alone  can  take  place  are  found  in  the  periosteum, 
more  especially  its  inner  layer,  the  cambium,  and  in  the  interior  of  bone. 
Eegeneration  of  bone  from  these  cells  takes  place  in  two  ways:  either  the 
cells  are  transformed  into  an  osteoid  tissue  or  they  are  first  changed  into 
cartilage-cells,  and  the  latter  at  a  later  stage  undergo  ossification.  The  osteo- 
blasts in  the  periosteum,  and,  to  a  lesser  extent,  those  in  the  central  medul- 
lary cavity,  produce  bone  by  this  indirect  method,  while  in  other  places 
ossification  is  effected  in  a  more  direct  way  by  the  osteoblasts  being  trans- 
formed into  an  osteoid  substance. 

In  the  normal  regeneration  of  bone  cartilage  plays  an  important  part. 


BONE.  57 

As  the  bone-cells  disappear,  or  at  least  lose  their  nuclei  where  cartilage- 
cells  form,  it  is  probable  that  the  cartilage-cells  represent  structures  inter- 
mediate between  osteoblasts  and  bone-cells.  Cartilage  is  abundant  where 
union  is  retarded,  and  especially  in  cases  of  pseudarthrosis.  During  ossifica- 
tion the  hyaline  cement-substance  between  the  cartilage-cells  is  dissolved, 
and  the  space  gives  way  to  lamellae,  while  the  cells  are  transformed  into 
bone-cells.  According  to  Krafft,  multiplication  of  the  bone-producing  cells 
of  the  periosteum  can  be  seen  twenty  to  thirty  hours  after  fracture,  in  the 
shape  of  karyokinetic  figures  in  the  nuclei  of  the  cells,  while  somewhat  later 
the  same  figures  are  to  be  seen  in  the  endothelia  lining  the  blood-vessels. 
The  new  cartilage-cells  also  multiply  by  karyokinesis.  Like  in  the  healing 
of  wounds  in  soft  parts,  the  cells  on  the  surface  of  the  fracture  take  no  part 
in  the  process  of  regeneration,  as  their  proliferative  capacity  has  been  de- 
stroyed by  the  trauma  as  well  as  the  sudden  diminution  of  the  vascular  sup- 
ply. Osteoporosis  at  the  seat  of  regeneration  is  always  present,  and  results 
from  the  action  of  another  kind  of  cells  discovered  by  Kolliker, — the  osteo- 
clasts. Eobin  described  them  as  my elo plaques.  They  are  found  in  How- 
ship's  lacunae,  where  resorption  takes  place. 

The  osteoclasts  appear  to  be  nothing  else  but  myeloid  cells  which  have 
lost  their  bone-producing  function;  they  are,  in  reality,  hyperplastic  osteo- 
blasts. Absorption  of  bone  takes  place  because  these  cells  do  not  produce 
bone.  There  is  no  reason  to  believe  that  these  cells  are  altered  bone-cells, 
as  no  intermediate  forms  have  been  found.  Ziegler  does  not  assign  much 
influence  to  these  cells  in  the  resorption  of  bone.  Wegner  has  shown  that 
in  pathological  processes  in  bone  where  resorption  takes  place  they  are 
arranged  along  the  sides  of  blood-vessels,  and  on  this  account  he  believed 
they  were  derived  from  the  vessel-wall.  Klebs  is  of  the  opinion  that  the 
osteoclasts  may  secrete  a  chemical  substance  which  decalcifies  the  bone. 
Eesorption  of  superfluous  callus  is  accomplished  undoubtedly  by  the  action 
of  osteoclasts,  an  exceedingly  useful  function,  as  by  it  form  and  strength  of 
the  broken  bone  are  restored. 

According  to  Meyer,  the  architectural  structure  of  the  spongiosa,  after 
the  healing  of  a  fracture,  adapts  itself  to  the  new  conditions,  so  that  the  new 
traction  and  pressure-curves  are  arranged  in  such  a  manner  as  will  resist  the 
greatest  degree  of  force.  This  capacity  of  adaptation  is  present  to  a  very 
high  degree  in  bone. 

Abnormal  and  Defective  Callus. — Callus  may  be  formed  in  excess  of 
local  requirements  after  a  fracture,  and  yet  no  union  take  place.  The  osteo- 
blasts respond  promptly  to  the  stimulus  created  by  the  trauma,  karyokinetic 
changes  occur  early,  new  cells  are  formed  with  great  rapidity,  and  a  large 
mass  of  new  material  is  deposited  at  the  seat  of  fracture,  but  bony  consolida- 
tion does  not  occur,  because  the  new  tissue  does  not  undergo  ossification. 


58  PRINCIPLES    OF    SUEGERY. 

The  normal  development  of  cells  is  arrested  at  an  early  stage,  and  the  chem- 
ical processes  upon  which  ossification  depends  are  delayed  or  fail  to  appear 
altogether.  Prompt  bony  union  does  not  only  imply  that  the  osteoblasts  at 
the  seat  of  fracture  should  undergo  karyokinetic  changes  and  multiply,  but 
that  the  new  tissue  must  be  placed  under  the  influence  of  favorable  chemical 
conditions  which  will  enable  it  to  be  transformed  into  bone. 

A  few  years  ago  B.  von  Langenbeck  reported  two  cases  of  fracture  of 
the  femur  where  he  resorted  to  amputation  of  the  thigh  under  the  belief 
that  the  luxuriant  callus,  which  formed  in  each  case  at  the  seat  of  fracture, 
was  a  sarcoma.  Microscopical  examination  in  both  instances  showed  that  the 
swelling  was  composed  of  cells  which  are  found  in  callus  at  an  early  stage 
of  its  formation,  without  any  evidences  of  ossification  of  the  new  material. 
The  causes  of  delayed  ossification  are  not  known,  but,  as  in  a  number  of 
instances  of  profuse  callous  formation  and  delayed  union  a  vigorous  anti- 


m 
^ 


w 


Fig.  34.— Osteoclasts  Absorbing  Bone.     A,  osteoclasts.     B,  osteoblasts. 

syphilitic  course  of  treatment  produced  favorable  results,  it  appears  that 
the  virus  of  syphilis  may  at  least  be  one  of  them.  We  know  that  in  gummata 
the  same  conditions  prevail  in  the  persistence  of  tissue  in  its  embryonal  state 
for  an  indefinite  period  of  time,  or  until  the  syphilitic  virus  has  been  re- 
moved or  neutralized  by  proper  antisyphilitic  treatment. 

In  cases  where  no  such  cause  for  the  delay  of  the  transition  of  callus  into 
bone  can  be  surmised,  the  internal  administration  of  minute  doses  of  phos- 
phorus should  be  tried.  KassoAvitz  produced  osteoporosis  in  animals  ex- 
perimentally by  large  doses  of  phosphorus,  while  minute  doses  produced  an 
opposite  effect.  He  recommended  the  remedy  in  small  doses  in  the  treat- 
ment of  rickets,  and  since  then  it  has  been  extensively  used  in  the  treatment 
of  this  disease,  and  with  the  best  results.  The  action  of  this  drug  undoubt- 
edly would  produce  a  favorable  effect  upon  the  osteoid  material,  in  hastening 
its  transition  from  the  embrvonal  into  a  mature  state. 


BONE.       '  59 

The  amount  of  callus  thrown  out  in  every  instance  depends  on:  1.  The 
general  condition  of  the  patient.  2.  The  location  and  structure  of  the  fract- 
ured bone.  3.  The  amount  of  local  injury.  4.  The  degree  of  displacement. 
5.  The  perfection  of  immobilization. 

As  a  rule,  a  minimum  amount  of  callus  is  produced  when  the  patient 
is  suffering  from  any  wasting  or  acute  febrile  affection  or  is  the  victim  of 
any  so-called  constitutional  diseases;  when  the  broken  bone  is  very  com- 
pact and  located  near  the  surface  of  the  body;  when  the  injury  was  slight, 
with  little  or  no  displacement,  and  when  during  treatment  the  broken  ends 
have  been  kept  at  rest  and  in  constant  and  in  uninterrupted  coaptation. 

Opposite  conditions  are  followed  by  an  exuberant  production  of  callus. 
The  influence  exercised  by  paraperiosteal  tissues  in  determining  the  amount 
of  callus  is  well  illustrated  in  fractures  of  the  tibia  and  ulna;  where  the  bone 
is  subcutaneous  little  or  no  callus  is  found,  while  in  places  where  it  is  deeply 
covered  by  muscular  and  aponeurotic  tissue  the  amount  of  callus  is  great, — 
in  some  instances  so  great  that  it  fills  the  entire  interosseous  space,  forming  a 
bridge  of  bone  across  it,  permanently  cementing  the  fibrda  or  radius,  as  the 
case  may  be,  to  the  broken  bone. 

To  obtain  bony  consolidation  after  a  fracture  certain  well-recognized 
conditions  are  necessary:  1.  A  sufficient  blood-sujaply  to  the  part.  2.  Un- 
impaired innervation  of  the  part.  3.  Placing  and  maintaining  the  frag- 
ments in  contact,  or  at  least  in  such  close  proximity  that  the  callus  thrown 
out  from  both  extremities  can  meet  and  establish  a  bony  bridge  between. 
Injury  of  any  principal  vessel  or  nerve  of  a  limb,  as  a  .complication  of  any 
fracture,  does  not  only  endanger  the  integrity  of  the  limb,  but  may  consti- 
tute an  important  element  in  the  production  of  non-union. 

Injury  of  the  nutrient  vessels  of  long  bones  has  no  influence  in  prevent- 
ing the  formation  of  callus,  claimed  by  several  writers,  inasmuch  as  the  com- 
bined statistics  from  the  practice  of  different  surgeons  do  not  sustain  this 
assertion.  An  excessive  supply  of  blood  in  the  part — either  from  an  undue 
afflux  of  blood,  the  consequence  of  an  excessive  irritation  about  the  seat  of 
fracture,  or  from  obstruction  to  the  venous  return — frequently  affects  callous 
formation  in  a  detrimental  manner.  These  conditions  often  interfere  with 
the  normal  reparative  process,  the  histological  elements  which  are  intended 
to  furnish  the  callus  not  undergoing  the  ty]oical  embryonal  tissue-transforma- 
tion. 

The  following  are  the  principal  causes  which  have  been  enumerated  as 
giving  rise  to  false  joints: — 

,   Rachitis.  Syphilis. 

General  i   ^i:°^^.^™^;.  Acute  febrile  affections. 

I   Wasting  diseases.  Preo-nancy 
L  Prolonged  lactation.  *=         -^ 


60 


PEINCIPLES    OF    SUEGEEY. 


f  Interposition  of  soft  tissue  between  fracture. 
I   Separation  of  fragments. 
I   Imperfect  immobilization. 
Local   -{   Imperfect  circulation  from  concomitant  swelling,  too  tight 
I  dressing,  or  position  of  limb. 

I    Obliquity  of  fracture. 
I,  Complication  of  fracture. 

I  have  not  enumerated  old  age  as  a  cause  for  delayed  or  non-union. 
Statistics  show  that  these  accidents  are  found  almost  exclusively  in  young 
people  at  the  age  of  20  to  35  years.    With  the  exception  of  joint  fractures. 


Fig.  35.  Fig, 

Fig.  35.— Old  Method  of  Bone-suture. 

Fig.  36. — ^Improved  Bone-suture.    Transverse  Fracture,  Wire  Suture  including 
Entire  Thickness  of  Both  Fragments. 

fractures  unite  promptly  and  in  a  short  time  in  the  aged.    Senile  osteoporosis 
may  be  considered  a  favorable  condition  for  a  callous  formation. 

A  great  diversity  of  opinion  prevails  among  surgeons  in  regard  to  the 
influence  of  general  conditions  on  the  production  of  callus.  Some  claim 
that  non-union  is  almost  invariably  due  to  general  causes.  I  recollect  very 
well  the  remark  of  the  late  Professor  von  E^ussbaum  on  this  subject.  In  a 
lecture  he  claimed  that  nearly  all,  if  not  all,  fractures  that  fail  to  unite  by 


Fig.  37.  Fig.  38. 

Fig.  37. — Wire  Drawn  through  the  Perforation. 
Fig.  38.— Wire  Cut  in  the  Centre  and  Each  Half  Twisted  Separately. 

bone  occur  in  patients  suffering  from  some  constitutional  taint,  more  espe- 
cially syphilis.  He  referred  to  several  cases  where  no  attempt  at  union  took 
place  imder  the  most  favorable  local  conditions,  and  where  a  course  of  mer- 
curial inunction  was  promptly  followed  by  bony  consolidation. 

Defective  callous  formation  will  necessarily  follow  a  fracture  if  the 
osteoblasts  fail  to  enter  upon  an  active  process  of  cell-proliferation.  These 
are  the  cases  where  the  surgeon  resorts  to  local  measures  which  are  intended 


BONE. 


61 


to  stimulate  the  cells  to  increased  activity.  Fractures  of  the  lower  extremi- 
ties which  have  failed  to  unite  as  long  as  the  patient  is  kept  in  bed  often 
unite  promptly  after  he  is  allowed  to  walk  around  on  crutches,  the  favorable 
change  being  brought  about  by  an  increased  blood-supply  to  the  seat  of 
fracture. 

Dumreicher  suggested  that  the  local  blood-supply  could  be  increased 
by  applying  a  compress  and  bandage  above  and  below  the  seat  of  fracture, 
while  Helferich  more  recently,  and  with  the  same  object  in  view,  advised 


Fig.  39. — Senn's  Hollow  Perforated  Intraosseous  Splint. 

moderate  constriction  with  an  elastic  bandage  applied  in  such  a  manner  as 
not  to  interfere  with  the  arterial  circulation.  Eubbing  of  the  fragments 
forcibly  against  each  other  is  an  old  method  of  treating  delayed  union,  and 
has  often  been  sufficient  to  rouse  the  dormant  osteoblasts  into  active  cell- 
proliferation.  The  distinguished  Brainard  made  the  treatment  of  delayed 
union  a  special  study  during  many  years  of  his  useful  life,  and  devised  a  new 
method  of  treatment, — the  subcutaneous  drilling  of  the  ends  of  the  frag- 
ments,— which  has  been  extensively  practiced  and  has  yielded  most  excel- 


Fig.  40.  Fig.  41.  ,  Fig.  42. 

Fig.  40. — Circular  Bone  Ferrule  for  Humerus  or  Femur  Made  of  an  Ox-femur. 
Fig.  41. — Triangular  Bone  Ferrule  for  Tibia  Made  of  an  Ox-tibia. 
Fig.  42.— Wide  Perforated  Bone  Ferrule. 

lent  results.  The  drilling  of  the  ends  of  the  broken  bone  has  a  most  de- 
cided effect  in  stimulating  the  sluggish  reparative  process,  as  it  produces 
osteoporosis  and  increases  the  vascularity  of  the  parts,  both  of  these  condi- 
tions being  well  calculated  to  increase  the  local  nutrition.  Dieffenbaeh  went 
one  step  farther,  and  advised  the  use  of  ivory  nails,  which  were  allowed 
to  remain  until  they  became  loose  and  dropped  out.  The  term  non-union 
is  a  relative  one,  as  in  some  fractures  this  condition  may  have  been  reached 
in  three  to  four  months,  while  others  may  unite  after  a  year. 


62 


PKINCIPLES    OF    SURGEKY 


In  a  fracture  of  the  femur,  in  a  healthy  man  who  came  under  the  au- 
thor's observation,  that  had  not  united  a  year  after  the  accident,  bony  con- 
solidation took  place  after  this  time  without  any  operative  interference.  In 
another  case  bony  union  did  not  occur  until  nearly  two  years  after.the  fract- 
ure had  taken  place.     When  a  pseudarthrosis  has  once  become  established, 


Fig.  43.  '  Fig.  44. 

Fig.  43.— Oblique  Fracture  of  Femur  United  by  Bone  Ferrule. 
Fig.  44.— Transverse  Fracture  of  Humerus  Immobilized  by  a  Wide  Perforated 

Bone  Ferrule. 

all  measures  which  have  been  found  useful  in  the  treatment  of  delayed 
union  are  useless,  and  the  only  rational  treatment  in  such  cases  consists  in 
transforming  the  old  fracture  into  a  recent  one.  The  ends  of  the  fragments 
are  exposed,  the  interposed  ligamentous  structures— muscles  or  tendons — or 
false  joint  excised,  and  the  ends  vivified  in  such  a  manner  as  to  furnish  large 
surfaces  for  apposition.     The  bone  should  never  be  cut  transversely,  but 


BONE. 


63 


always  obliquely,  or,  what  is  still  bef;ter,  Volkmann's  step-operation  should 
he  done  wherever  the  existing  conditions  make  this  possible.  Direct  fixa- 
tion of  the  fragments  with  aseptic  bone  or  ivory  nails  should  always  be  prac- 
ticed, as  by  this  expedient  we  are  able  to  secure  greater  immobility  between 
the  fragments,  and  at  the  same  time  the  perforations  and  the  presence  of 
the  foreign  bodies  cannot  fail  in  imparting  an  additional  stimulus  to  the 
tissues  which  will  expedite  the  process  of  repair. 

The  silver-wire  suture  has  been  used  for  a  long  time  to  secure  fixation 
of  the  fragments  in  recent  fractures  and  in  cases  of  non-union. 


Fig.  45.— Senn's  Splint  Apparatus  Applied;    Pad  Making  Pressure  over 
Trochanter  in  the  Direction  of  Neck  of  Femur. 


In  uniting  oblique  fragments  Wille's  method  of  suturing,  shown  in 
Figs.  37  and  38,  is  to  be  preferred.  Bircher  has  employed  cylinders  of  ivory, 
which  he  introduced  into  the  medullary  cavity  as  a  means  of  fixation.  The 
writer  has  substituted,  for  the  solid  ivory,  hollow  perforated  intraosseous 
splints  to  meet  the  same  indications.  As  another  means  of  direct  fixation, 
the  author  has  devised  and  successfully  employed  bone  ferrules  in  a  number 
of  cases.  The  shape,  size,  and  application  of  these  ferrules  are  well  shown 
in  the  accompanying  illustrations.     (Figs.  39  to  42.) 

The  frequency  with  which  non-union  is  met  with  after  intracapsular 
fracture  of  the  neck  of  the  femur  has  almost  by  universal  consent  been  at- 


64 


PEINCIPLES    OF    SUKGERY. 


tributed  to  defective  callous  formation.  It  has  been  claimed  that  in  such  a 
fracture,  occurring  as  it  usually  does  in  persons  advanced  in  life,  callous 
production  is  always  defective,  and,  as  the  upper  fragment  is  but  scantily 
supplied  with  blood-vessels,  it  was  asserted  that  it  was  not  in  a  condition 
to  take  an  active  part  in  the  reparative  process.  The  author  made  numerous 
experiments  on  animals,  fracturing  the  neck  of  the  femur  within  the  limits 
of  the  capsular  ligament,  and  as  long  as  the  fracture  was  treated  in  the  cus- 
tomary way  bony  union  was  never  attained.  He  then  resorted  to  direct  means 
of  fixation  by  transfixing  both  fragments  with  an  absorbable  nail,  and  with 
this  treatment  succeeded  in  obtaining^bony  union  in  the  majority  of  cases. 
Since  that  time  he  has  treated  fractures  of  the  neck  of  the  femur  by  im- 
mediate reduction  and  permanent  fixation  with  a  plaster-of-Paris  splint,  with 
pressure  over  the  trochanter  major  in  the  direction  of  the  axis  of  the  neck 
of  the  femur  with  a  compress  and  set-screw,  the  latter  passing  through  a 


Fig.  46. — Senn's  Splint  Apparatus  for  Treating  Fracture  of  Neck  of  Femur. 


splint  which  is  incorporated  in  the  plaster-of-Paris  dressing.  With  this  treat- 
ment he  has  obtained  bony  union  in  a  number  of  instances  where  all  the 
signs  and  symptoms  pointed  to  a  fracture  within  the  capsular  ligament. 

It  is  a  well-established  clinical  fact  that  in  the  aged  other  fractures 
unite  readily,  and  pseudarthrosis  is  exceedingly  uncommon,  excepting  after 
this  fracture;  and  the  writer  is  satisfied  that  this  undesirable  result  occurs 
more  in  consequence  of  improper  treatment  than  defective  callous  pro- 
duction. If  the  fragments  can  be  brought  in  accurate  apposition  soon 
after  the  accident  has  occurred,  and  coaptation  can  be  maintained  uninter- 
ruptedly for  three  months  by  an  appropriate  dressing,  bony  union  can  be 
secured,  not  only  in  exceptional,  but  in  the  majority  of,  cases.  In  the  treat- 
ment of  fractures,  as  in  the  treatment  of  wounds  of  the  soft  parts,  accurate 
coaptation  and  effective  fixation  should  be  aimed  at,  so  as  to  place  the  parts 
in  the  most  favorable  condition  to  unite  by  the  smallest  possible  amount  of 
new  material. 


GLANDS.  65 


GLANDS. 


Testicle. — Griffini  studied  regeneration  of  testicle-substance  in  frogs, 
dogs,  chickens,  and  guinea-pigs.  He  excised  a  wedge-shaped  piece  under 
strict  antiseptic  precautions,  and  killed  the  animals  in  from  three  to  seventy- 
five  days.  Examination  of  the  specimens  showed  that  an  increase  of  tubuli 
seminiferi  had  invariably  taken  place.  They  appeared  to  have  originated  as 
blind  pouches  from  preexisting  tubules. 

Liver. — Tizzoni  has  also  observed,  in  his  experiments  on  dogs,  produc- 
tion of  new  gland-tissue  during  the  healing  of  wounds  of  the  liver  and  after 
partial  excision  of  this  organ. 

Ponfick  studied  regeneration  of  liver-tissue  in  dogs  and  rabbits,  remov- 
ing two-thirds  to  three-fourths  of  the  organ.  The  animals  were  killed  in 
from  two  to  fifty  days.  Karyokinetic  changes  were  seen  as  early  as  the 
second  day.  Following  regeneration  of  the  parenchyma,  vascularization  of 
the  new  tissue  set  in  promptly.  Eegeneration  of  the  biliary  ducts  was 
studied  by  injecting  indigo-carmin  into  the  circulation.  The  animals  were 
killed  in  from  one  and  one-half  to  two  hours,  and  even  at  this  early  period 
after  operation  distinct  evidences  of  a  beginning  process  of  repair  were  de- 
tected. There  are  now  a  number  of  cures  recorded  in  which  extensive  losses 
of  liver-tissue  caused  by  injury  or  operation  in  the  human  were  repaired 
without  any  functional  disturbances  following. 

Spleen. — The  same  author  studied  experimentally  regeneration  of  the 
spleen-tissue,  and  found  that  this  occurred  after  partial  and  complete  ex- 
tirpation, the  new  tissue  being  made  up  of  elements  in  connection  with 
blood-vessels  of  the  adjacent  peritoneum.  After  complete  extirpation  of 
the  organ  the  new  spleens  appear  as  nodules  of  a  brownish  color,  which  are 
attached  to  the  vessels  of  the  peritoneum,  and  develop  around  new  buds  of 
these  vessels.  The  beginning  of  such  a  minute  spleen  appears  as  an  accumu- 
lation of  new,  loose,  connective  tissue,  in  the  meshes  of  which  lymph-cor- 
puscles are  found;  later,  follicles  and  pulp-substance  appear,  with  a  corre- 
sponding arrangement  of  blood-vessels.  As  these  little  organs  always  appear 
about  the  hilum  of  the  spleen,  they  cannot  be  supernumerary  spleens.  After 
excision  of  wedge-shaped  pieces  of  the  spleen,  formation  of  new  spleen-tissue 
has  also  been  observed  upon  the  omentum  at  a  point  opposite  the  wound  and 
independently  from  tissue-proliferation  in  the  wound.  Eeproduction  of 
tissue  therefore  takes  place  in  the  same  manner  as  in  the  regeneration  of 
lymphatic  tissue.  After  the  removal  of  the  entire  spleen,  tissue-proliferation 
takes  place  in  the  adjacent  blood-vessels,  the  product  of  which  corresponds 
with  normal  splenic  tissue,  and  doubtless  possesses  the  same  physiological 
functions.  As  the  immediate  result  of  such  proliferation,  an  altered  condi- 
tion of  the  vessels  must  be  accepted,  as  the  blood-vessels  of  the  omentum 


e6 


PEINCIPLES    OF    SURGERY. 


and  peritoneum  correspond  with  the  fundus  of  the  stomach.  Mayer  claimed 
regenerative  capacity  for  the  pulp  of  the  spleen,  but  he  may  have  been  de- 
ceived by  the  presence  of  lymphatic  glands  of  the  color  of  the  spleen  at  the 
seat  of  extirpation.  Picard  and  Malassez,  Bizzozero  and  Salvioli,  and  finally 
Tizzoni  and  Fileti  showed  that  after  splenectomy  a  diminution  of  the  blood- 
corpuscles  is  observed  first,  but  as  the  new  spleen-tissue  is  produced  their 
number  again  increases. 

Lymphatic  Glands. — Bayer  and  Bacialli  have  shown,  by  their  experi- 
mental investigations,  that  new  Ij'-mphatic  tissue  is  rapidly  produced  after 
partial  as  well  as  after  complete  removal  of  a  lymphatic  gland.  In  the  regen- 
eration of  this  tissue  the  adjacent  adipose  tissue  appeared  to  take  an  active 


Fig.  47.— Wound  of  Kidney,  Fourth  Day.  Large  regeneration-cells  of  different  forms 
(6) ;  a,  blood-extravasation  containing  new  cells  (c)  produced  by  coalescence  of  leuco- 
cytes.    (Tillmanns.) 


part.  According  to  Bayer,  the  adipose  tissue  is  first  infiltrated  with  leuco- 
cytes, while  Bacialli  saw  new  endothelial  cells  and  lymph-spaces  develop 
from  the  connective-tissue  cells,  after  having  seen  mitotic  figures  in  the 
nuclei.  After  complete  extirpation  of  a  lymphatic  gland,  reproduction  of 
lymphoid  structure  in  all  probability  does  not  take  place  from  any  other  but 
lymphatic  tissue,  and  the  new  gland-tissue  is  the  product  of  tissue-prolifera- 
tion from  the  cut  ends  of  lymphatic  vessels. 

Kidney. — The  experiments  of  TuJffier  have  demonstrated  that  the  kid- 
ney is  endowed  with  a  recuperative  capacity  which  is  common  to  nearly  all 
of  the  glandular  organs.  They  show  that  it  is  possible  to  successively  re- 
move a  large  part  of  the  normal  renal  tissue,  and  that,  after  a  certain  num- 
ber of  days, — the  sooner,  the  less  renal  parenchyma  removed, — the  specific 


CEXTEAL    KEEVOUS    SYSTEM.  67 

gravity  of  the  urine  and  the  excretion  of  urea  are  perfectly  reestablished,  and 
that  compensation  was  due  partially  to  hypertrophy  of  the  remaining  paren- 
chyma and  partially  to  the  new  formation  of  glomeruli,  and  this  happened 
even  in  cases  of  animals  in  which  one  kidney  had  already  been  extirpated, 
and  was  folloAved  by  a  partial  removal  of  the  kidney  on  the  other  side. 
Tuffier,  as  a  result  of  his  experiments,  states  that,  in  animals,  from  15  to  33 
grains  of  renal  gland-tissue  are  sufficient  for  two  pounds  of  weight.  Esti- 
mating the  weight  of  the  human  body  at  one  hundred  and  forty  pounds, 
from  1200  to  1500  grains  of  renal  parenchyma,  apart  from  the  capsule,  which 
is  not  counted,  are  sufficient  to  maintain  life.  This  would  amount  to  about 
one-third  or  one-fourth  of  the  normal  organ.  Surgically,  therefore,  it  is 
possible  to  remove  a  large  part  of  the  kidne}^  the  remaining  portion  still 
retaining  its  function;  and  in  partial  destruction  of  the  renal  tissue  it  is 
not  necessary  to  remove  the  whole  organ,  and  we  can  be  satisfied  with  a  par- 


Fig.  48.— Healing  of  Wound  of  Liver,  Tenth  Day.  a,  young  connective  tissue;  b, 
liver-tissue  at  the  margin  of  the  wound,  showing  fatty  degeneration,  and  infiltrated  with 
red  and  white  blood-corpuscles.     (Hartnack  3,  oc.  iii.)     (Tillmanns.) 

tial  excision,  es]Decially  if  the  condition  of  the  other  kidney  is  not  known. 
Partial  excision  may  become  necessary  in  injuries  of  this  organ,  in  circum- 
scribed abscesses,  and  non-malignant  tumors.  Successful  partial  nephrec- 
tomy has  been  done  by  Herczl,  Kiimmell,  James  Israel,  and  others.  Success- 
ful partial  nephrectomies  have  usually  been  performed  for  circumscribed 
inflammatory  affections,  and  there  is  every  reason  to  believe  that  the  defect 
was  repaired  in  part,  at  least,  by  regeneration  to  the  same  extent  as  in  the 
experiments  on  animals. 

CENTRAL    NERVOUS    SYSTEM. 

The  central  nervous  system  is  built  up  partly  from  the  mesoblast  and 
partly  from  the  epiblast.  The  stellate  and  spider-shaped  cells  are  derived 
from  the  mesoblast,  while  the  neuroglia  and  the  nerve-cells  proper  spring 
from  the  neuroblast,  a  part  of  the  epiblast,  which,  in  the  embryo,  is  located 
nearest  the  middle  axis.     The  neuroglia  represent  channels  of  nutrition. 


68  PEINCIPLES    OF    SUEGERY. 

which  are  formed  only  at  a  time  when  the  neuroblastic  tissues  have  reached 
the  height  of  their  development.    The  mesoblastic  portion  of  the  brain  and 
spinal  cord  does  not  increase  during  the  healing  of  a  wound  of  these  parts. 
In  pathological  conditions,  however,  as  in  cases  of  multiple  sclerosis,  the 
stellate  and  spider-shaped  elements  proliferate  so  actively  that  the  nerve- 
cells  are  completely  displaced  by  the  new  product.    Many  authors  have  ex- 
pressed their  doubts  as  to  the  possibility  of  regeneration  of  brain-tissue  after 
injury  or  disease,  while  others  have  gone  to  the  opposite  extreme  and  claim 
that  complete  repair  can  take  place  in  cases  of  extensive  defects.    Voit  claims 
that  in  pigeons  he  has  observed  complete  restoration  of  both  structure  and 
function  after  extirpation  of  the  entire  cerebrum.     Vitzow  destroyed  the 
occipital  lobes  in  monkeys  and  found  that  vision  which  was  completely  de- 
stroyed was  gradually  restored.    Histological  examination  proved  that  the 
restoration  of  sight  was  due  to  production  of  new  nerve-cells  and  fibres. 
Tedeschi  is  somewhat  skeptical  on  the  subject  of  repair  of  large  defects  of 
the  central  nervous  system.    He  produced  wounds  in  the  cortex  of  animals. 
As  the  immediate  consequence  of  the  injury  degeneration  and  limited 
necrosis  followed.    However,  in  a  short  time  a  limited  process  of  repair  was 
initiated  in  the  adjacent  tissue.    The  endothelial  cell  formed  capillaries  and 
the  neuroglia  glia  tissue,  which  constituted  the  main  portion  of  the  scar. 
Karyokinetic  figures  were  seen  in  some  of  the  ganglia-cells,  and  later  nerve- 
fibres  were  also  found  in  the  scar,  showing  that  a  limited  process  of  repair 
followed  the  primary  degeneration.     While  large  defects  are  not  repaired, 
the  regenerative  capacity  of  the  nervous  elements  cannot  be  doubted,  and 
such  a  doubt  would  come  in  conflict  with  a  general  law.     Eegeneration  of 
the  cerebral  nervou.s  system  comprises  the  production  of  new  ganglia-cells 
and  neuroglia.,  the  latter  consisting  of  a  fine  net-work,  sometimes  of  nervous, 
at  others  of  basic,  substance.    During  the  healing  of  every  wound  of  the  brain 
the  observer  can  satisfy  himself  that  the  neuroglia  possesses  a  high  capacity 
of  reproduction,  as  well-marked  karyokinetic  changes  can  be  seen  during 
the  first  twenty-four  hours  after  injury.    The  new  cells  are  very  abundant, 
and  arrange  themselves  in  groups.    More  diflicult  is  the  demonstration  of 
the  same  changes  in  the  ganglia-cells,  but  Mondino  (1886)  and  Coen  (1887) 
have  given  descriptions  of  these  cells  which  leave  no  further  doubt  that  they 
also  multiply  by  karyokinesis.    Klebs  has  also  observed  karyokinetic  figures 
in  the  nuclei  of  ganglia-cells  during  the  repair  of  injuries  of  the  brain.    In 
the  embryo,  increase  of  ganglia-cells  by  karyokinesis  has  been  witnessed  by 
Pfitzner,  Uskoff,  Eauber,  Merk,  and  Cattani.    It  is  true  that  brain  wounds 
heal  with  some  defects,  but  this  applies  to  extensive  injuries  in  which  the 
regenerative  capacity  of  the  brain-substance  is  not  equal  to  the  emergency; 
hence,  only  a  part  of  the  defect  is  repaired.    Klebs  gives  an  accurate  account 
of  his  examination  on  the  reparative  process  in  two  cases  of  brain  injury: 


CENTEAL    NEEVOUS    SYSTEM.  69 

one  recent,  the  other  of  long  standing.  Microscopical  examination  of  the 
tissues  from  the  seat  of  injury  in  both  cases  showed  that  new  tissue  had  been 
produced.  He  found  many  new  cells  from  the  neuroglia  which  he  is  inclined 
to  believe  may  functionally  take  the  place  of  ganglia-cells.  The  same  author 
made  numerous  experiments  on  young  animals  for  the  purpose  of  studying 
the  process  of  healing  in  wounds  of  the  brain.  With  an  aseptic  needle  the 
brain  was  punctured.  No  symptoms  followed  the  injury.  The  brain  was 
examined  from  two  to  four  days  after  puncture;  only  slight  meningeal 
hgemorrhage.  The  needle-track  in  the  brain  not  closed.  Mitotic  changes 
were  found,  not  in  the  cells  in  the  immediate  neighborhood  of  the  puncture, 
but  in  the  cells  corresponding  to  from  the  second  to  the  fifth  row  from  it. 
In  the  same  place  were  found  an  accumulation  of  resting  nuclei.  Mitotic 
cell-proliferation  of  injured  cells  was  found  completed  on  the  fourth  day. 
Ganglia-cells  undoubtedly  increase  in  number  in  the  same  manner.  He 
found  no  leucocytes  in  the  brain,  and  believes  that  those  that  must  have 
been  present  had  been  appropriated  as  food  by  the  cells  which  had  under- 
gone karyokinetic  changes.  The  gray  matter  of  the  surface  of  the  brain  is 
composed  of  numerous,  but  exceedingly  small,  cells,  and  their  numerous  con- 
nections would  indicate  great  reproductive  capacity. 

Peripheral  Nerves. — When  Cruikshank  suggested  the  possibility  of  re- 
storing physiological  function  in  a  divided  nerve  by  suturing,  his  contem- 
poraries regarded  the  suggestion  as  an  absurdity.  Since  that  time  the  sub- 
ject of  nerve-regeneration  has  engaged  the  attention  of  some  of  the  best 
men  in  the  profession,  and  from  the  knowledge  which  has  thus  accumulated 
it  is  safe  to  repeat  the  statement  made  by  Van  Lair  recently,  that  "the  sur- 
geon who  neglects  to  suture  a  divided  nerve  commits  the  same  mistake  as  he 
who  neglects  to  reduce  a  fracture  or  fails  to  unite  a  divided  tendon."  Re- 
generation of  a  nerve  takes  place  exclusively  from  preexisting  nerve-fibres. 
Schwann's  sheath  isolates  the  nerve-fibre  so  thoroughly  from  the  mesoblast 
that  it  would  be  almost  impossible  for  the  latter  to  take  any  direct  or  active 
part  in  the  regeneration  of  the  former.  The  neuroblasts  from  which  tissue- 
proliferation  takes  place  are  found  within  the  nerve-sheath.  Confluence  of 
the  new  nerve-elements  within  the  neurolemma  does  not  take  place,  as,  ac- 
cording to  Cattani,  they  receive  envelopes  from  the  medulla.  The  part 
played  by  the  cells  of  the  sheath  of  Schwann  in  the  regeneration  of  nerves 
has  become  to  be  a  moot  question.  Von  Bungner,  Galrotti  and  Levi,  Ziegler 
and  von  Wieting  have  claimed  that  these  cells  are  a  kind  of  neuroblast  the 
protoplasm  of  which  gives  origin  to  parts  of  the  new  axis-cylinders.  Kolster 
and  Huber  traced  the  formations  of  the  myelin  in  the  regenerating  nerve 
to  differentiation  in  the  protoplasm  of  Schwann's  cells,  while  others  main- 
tained that  the  myelin-sheath  grows  down  simultaneously  with  the  axis- 
cylinders.     Section  of  a  motor  fibre  is  at  once  followed  by  degeneration  of 


70  PKINCIPLES    OF    SUEGERY. 

the  motor  terminal  part;  hence,  degeneration  and  regeneration  in  the 
divided  nerve  and  the  muscles  supplied  by  it  are  parallel  processes.  Degen- 
eration and  regeneration  have  been  studied  in  nerves  that  were  stretched, 
lacerated,  or  completely  cut  across,  and  the  histological  processes  were  found 
almost  identical  in  all  of  these  conditions.  The  study  of  degenerative  and 
regenerative  processes  side  by  side  in  injured  nerves  has  thrown  much  light 
upon  their  minute  anatomy.  The  medullated  peripheral  nerve-fibres  is  com- 
posed essentially  of  Schwann's  sheath,  the  axis-cylinder,  and  a  fluid  which 
appears  as  a  periaxial  layer.  Klebs  looks  upon  this  fluid  as  a  sort  of  nervous 
endolymph,  which,  by  virtue  of  its  great  mobilit}'',  takes  part  in  the  nutri- 
tion of  the  nerve.  The  space  which  contains  the  fluid,  being  between  the 
axis-cylinder  and  the  sheath,  serves  not  only  the  purpose  of  a  channel  for 
the  fluid,  but  also  for  the  dissemination  of  movable  elements, — as,  for  in- 
stance, migration-corpuscles.  Leucocytes  are  only  present  in  any  consid- 
erable numbers  in  pathological  conditions.  Schwann's  sheath  is  composed 
of  connective  tissue.  The  large  oval  nuclei,  containing  each  one  or  two. 
shining  nucleoli,  which  are  attached  to  its  inner  side,  are  the  neuroblasts. 
It  is  as  yet  not  definitely  settled  whether  the  portion  of  nerve  between  two 
of  Eanvier's  constrictions  is  composed  of  one  or  more  cells.  Eeclus  accepts 
.  Eanvier's  theory,  that  the  new  nerve-elements  originate  from  the  axis- 
cylinder  of  the  central  end,  and  generally  from  Eanvier's  ring  nearest  the 
section.  A  single  myelin-fibre  is  produced  here,  or  an  axis-cylinder  which 
later  is  enveloped  by  myelin.  From  this  tube  new  tubes  are  formed,  finally, 
from  twenty-five  to  forty  in  number,  which  approach  the  peripheral  end, 
insinuate  themselves  into  empty  Schwann's  sheaths  or  the  spaces  between 
them.  Klebs  is  inclined  to  accept  the  view  that  such  a  space  is  represented 
by  one  cell,  and  if  several  nuclei  are  present  they  are  the  product  of  nuclear 
segmentation.  The  nuclei  must  be  regarded  in  the  light  of  peripheral  nerve- 
cells.  The  specific  functional  contents  of  a  nerve-fibre  are  the  axis-cylinder, 
the  endolymph,  and  medulla.  The  first  two  are  continuous  with  the  neigh- 
boring elements,  but  not  so  the  medullary  sheath.  The  medullary  sheath  is 
a  very  complicated  structure.  The  masses  of  fat  are  held  together  and  are 
inclosed  by  a  frame-work  of  keratin.  Finer  keratin-threads  unite  both 
sheaths  in  the  form  of  Golgi's  spirals,  which  are  present  in  the  funnels  of 
Schmidt-Lautermann's  medullary  spaces;  besides,  numerous  transverse 
threads  are  strung  out  in  zigzag  shape  between  the  sheaths.  The  constituent 
parts  of  the  medullary  portion  of  the  nerve-fibre  can  disappear  separately; 
if  the  medullary  fat  is  removed  by  absorption,  the  keratin  frame-work  be- 
comes visible:  a  condition  which  is  present  during  the  early  stages  of  neu- 
ritis parenchymatosa.  If  the  keratin  frame-work  is  dissolved,  the  fat  ap- 
pears in  drops,  as  can  be  seen  during  the  degeneration  of  a  nerve  after  sec- 
tion.    The  axis-c5dinder  is  a  preexisting  structure,  which,  however,  can  be 


CENTKAL  NERVOUS  SYSTEM. 


71 


only  distinctly  outlined  against  tlie  medullary  sheath  and  endolymph  by 
post-mortem  influences.  Its  structure,  in  the  larger  medullated  fibres  at 
least,  is  not  simple,  but  is  composed  of  fine  fibrillge,  held  together  by  an 
amorphous,  gelatinous  substance.  Physiologically,  this  part  of  the  nerve 
must  be  regarded  as  a  complex  of  difl:erent  conductors,  which  only  differ  by 
the  qualities  of  motility  and  sensibility.  Regeneration  of  a  peripheral  nerve- 
fibre  is  a  regular  typical  process,  as  far  as  it  serves  as  a  substitute  for  lost 
elements  of  a  nerve.  The  process  resembles  the  physiological  growth  of  a 
nerve,  which  always  occurs  only  in  connection  with  the  central  nervous  sys- 
tem. If  the  separation  between  the  nerve-ends  exceeds  an  inch,  restoration 
of  its  continuity  without  assistance  cannot  take  place.  In  such  an  event  the 
ends  become  bulbous,  the  medullary  substance  in  the  distal  portion  under- 
goes degeneration,  and  the  axis-cylinder  becomes  more  and  more  indistinct. 
The  same  changes  take  place  in  the  nerve-ends  after  amputation.    When  a 


Fig.  49. — Tubular  Suture  of  Van  Lair  with  Decalcifled-Bone  Tube.  Transverse  Sec- 
tion, a,  concentric  fissures;  6,  radiating  fissures;  c,  central  canal,  showing  new  nerve- 
flbres. 

nerve  is  simply  divided  and  there  is  no  loss  of  substance,  the  ends  remaining 
in  close  contact,  function  is  established  in  a  remarkably  short  time.  In  two 
instances  Gluck  observed  perfect  function  within  twenty-four  hours.  He 
concludes  that  the  granulation-tissues  must  have  been  the  means  of  conduc- 
tion in  these  cases.  In  his  experiments  on  the  sciatic  nerve  in  fowls,  where 
he  divided  the  nerve  and  immediately  sutured  with  catgut,  function  was  re- 
stored in  from  fifty  to  eighty-six  hours.  Waller  and  Van  Lair  are  of  the 
opinion  that  regeneration  proceeds  entirely  from  the  proximal  end.  Ac- 
cording to  Van  Lair,  the  zone  of  proliferation  extends  one  and  one-half  to 
two  and  one-half  centimetres  above  the  divided  end,  and  the  new  material  is 
principally  furnished  by  the  cortical  tubes.  The  young  fibres  may  attain  a 
length  of  from  one  to  even  six  centimetres;  beyond  this  distance  they  require 
the  support  of  empty  nerve-sheaths.  If  such  a  support  is  not  present  the 
new  fibres  cease  to  grow  and  undergo  atrophy.    Whqn  there  is  a  space  be- 


72 


PEINCIPLES    OF    SUEGEKY. 


tween  the  severed  nerve-ends,  tlie  fibres  easily  penetrate  through  the  cica- 
tricial tissue  as  long  as  it  is  embryonal.  Upon  this  observation  are  based 
the  experiments  of  Van  Lair,  who  secured  union  between  nerve-ends  widely 
separated  by  interposing  between  them  a  decalified-bone  tube,  the  new  nerve- 
fibres  following  the  Haversian  canal  or  the  fissures  caused  by  absorption. 

By  Van  Lair's  method  a  distance  of  six  to  seven  centimetres  has  been 
successfully  bridged.  The  time  required  in  the  repair  of  such  large  defects 
depends  on  the  age  of  the  patient, — from  three  to  eight  months.  Colasanti 
claims  that  degeneration  of  the  peripheral  end  only  extends  as  far  as  the 


Fig.  50.— Nerve-fibre  in  a  State  of  Regeneration  Fifty  to  Seventy  Hours  after  In- 
jury. A,  proliferation  of  neuroblasts;  B,  spindle  cell,  which,  becoming  confluent  with 
similar  cells  from  both  sides,  unites  the  nerve-flbres;  O,  rows  of  spindle  cells,  forming 
amyelinic  nerve-fibres;  B,  young  amyeloid  cells,  formed  from  nuclei  of  neurolemma. 
(GZMCfc.) 


next  Eanvier  ring,  while  Tizzoni  found  that  degeneration  extends  from  the 
seat  of  injury  in  both  directions,  only  that  it  is  more  marked  on  the  distal 
side.  Most  of  the  recent  writers  on  the  subject  assert  that  when  a  piece  of 
the  nerve  is  resected  the  entire  nerve  on  the  distal  side  undergoes  degenera- 
tion, while,  if  the  nerve  is  only  divided  and  the  ends  are  immediately  sutured, 
at  least  a  number  of  the  nerve-fibres  retain  their  integrity.  Eichhorst  and 
others,  who  have  made  regeneration  of  the  nerves  a  special  stud}^,  are  of  the 
opinion  that  the  nerve-fibres  of  both  ends  participate  in  the  process  of  repair, 
and  that  regeneration  commences  with  degeneration.  Eichhorst  believes 
that  regeneration  takes  place  exclusively  by  splitting  of  the  axis-cylinder 


CENTRAL    NEEVOUS    SYSTEM. 


73 


within  Schwann's  sheath,  so  that  the  latter  in  the  course  of  time  becomes 
distended  with  the  product  of  proliferation.  Continuity  is  restored  by  the 
central  fibrils  being  pushed  outward  through  the  cicatrix  to  meet  the  periph- 
eral, and  coalescence  follows.  Beneke,  on  the  other  hand,  traced  the  origin 
of  the  new  fibres  to  protoplasm  of  the  neuroblasts,  which  are  transformed 
into  delicate  fibrils,  which  become  surrounded  by  a  coating  of  myelin:  the 
future  medulla.  It  is  more  probable  that  regeneration  of  a  nerve  takes  place 
by  the  latter  method.  After  a  trauma  reproduction  of  the  axis-cylinder  al- 
ways follows.  According  to  a  number  of  investigators  who  have  studied  this 
subject,  several  axis-cylinders  are  formed  within  each  Schwann  sheath,  each 


1  ,' 


Fig.  51. — Longitudinal  Section  through  Nerve  Twenty-one  Days  after  Injury,  show- 
ing  Medullated   and    Non-medullated    Nerve-fibres   with    Round    Cells    between    them. 


of  which  is  surrounded  by  a  separate  medullary  sheath.  It  is  difficult  to 
ascertain  whether  these  new  fibres,  growing  out  of  one  of  the  old  fibres,  again 
become  united  some  distance  toward  the  periphery,  or  whether  they  remain 
isolated  to  their  point  of  peripheral  distribution.  After  nerve-section  the 
axis-cylinder  swells  at  the  cut  end  and  becomes  striated;  this  swelling,  how- 
ever, is  not  an  active  process,  but  the  result  of  imbibition  of  stagnant  endo- 
lymph.  The  longitudinal  striations  and  formation  of  vacuoles  which  have 
been  described  by  Tizzoni  are  due  to  the  same  cause.  The  granular  appear- 
ance is  brought  about  by  disintegration  of  the  fibrillse.  The  old  axis-cylinder 
breaks  down  into  isolated  fragments,  which,  in  part  at  least,  are  removed  by 


74  PRINCIPLES    OF    SURGERY. 

leucocytes,  wMcli  at  this  time  have  made  their  appearance.  With  such  ex- 
tensive destructive  changes  in  the  axis-cylinder  it  is  difficult  to  conceive  how 
regeneration  of  this  structure  could  take  place  in  the  manner  described  by 
Eichhorst.  The  only  histological  elements  within  the  fibre-sheath  exempt 
from  degeneration  are  the  nuclei  of  the  inner  surface  of  the  sheath,  the  neu- 
roblasts, and  from  these  regeneration  takes  place. 

At  the  seat  of  regeneration  the  nerve  is  enlarged  from  the  accumulation 
of  the  products  of  tissue-proliferation  within  the  neurolemma-sheaths. 

The  first  stage  of  regeneration  of  a  nerve  is  initiated  by  multiplication 
of  the  neuroblasts  and  increase  of  protoplasm.  The  nuclei  increase  to  double 
their  normal  size  and  then  divide  into  two  or  more.  Division  of  nuclei  prob- 
ably takes  place  by  karyokinesis.  The  protoplasm  is  granular,  and  is  stained 
a  reddish  color  with  neutral  picrocarmin.  The  nerve-fibre  originates  from 
the  protoplasm,  and,  according  to  Tizzoni,  in  the  forpa  of  separate  pieces, 
around  which  already  can  be  distinguished  a  medullary  sheath  and  trans- 
parent contents.  In  other  cases  there  may  be  a  direct  connection  between 
the  old  and  new  axis-cylinder.  Longitudinal  striation  of  the  axis-cylinder 
probably  takes  place  at  a  time  when  the  fibre  has  formed  a  direct  connection 
with  distant  parts,  the  seat  of  active  physiological  processes.  Leucocytes 
have  been  found  within  the  neurolemma  by  Tizzoni  and  Korybut-Daskiewicz, 
while  Neumann  denies  their  presence  in  this  locality.  Cattani  believes  that 
they  are  present  within  the  fibre-sheath  after  nerve-stretching,  and  can  be 
found  as  far  as  the  motor  ganglia  of  the  cord.  Nerves  of  different  function, 
when  united,  will  undergo  repair  and  establish  useful  conductors  for  the 
transmission  of  nerve-force.  The  late  Professor  Gunn  established  the  cor- 
rectness of  this  assertion  by  a  series  of  interesting  experiments  on  dogs. 
Early  functional  results  after  nerve-suture  are  often  fallacious,  as  the  func- 
tion attributed  to  sutured  nerves  may  be  performed  by  other  nerves  which 
reach  over  such  areas;  and,  again,  the  peripheral  manifestation  may  be  the 
result  of  physical  conduction  of  the  irritation,  and  apparent  motor  recoveries 
may  be  stimulated  by  the  action  of  muscles  other  than  those  supplied  by  the 
sutured  nerve. 

NERVE-SUTURE. 

ISTerve-suture  was  first  performed  by  Baudens  in  1836,  with  negative 
result.  The  procedure  was  revived  by  Nelaton  in  1863,  and  the  following 
year  by  Langier.  The  first  operations  were  made  with  fine-silk  sutures, 
which  were  not  out  short,  and  subsequently  came  away  by  suppuration. 
Failures  will  occasionally  follow  both  primary  and  secondary  nerve-suture 
in  spite  of  good  coaptation,  as  such  results  may  be  due  to  secondary  degen- 
eration of  motor  nerve-cells  in  the  cord,  as  was  suggested  by  Willard.  0. 
Weber  advised  the  uniting  of  the  nerve-ends  by  passing  the  sutures,  not 


NERVE-SUTUEE. 


75 


through  the  nerve-substance,  but  only  through  the  connective  tissue  sur- 
rounding the  nerve:  the  paraneural  suture.  Experience,  however,  has  shown 
that  transfixion  of  the  nerve-ends  by  the  sutures  does  not  give  rise  to  pain, 
and  does  not  interfere  with  the  normal  reparative  processes,  and  at  the  same 
time,  by  resorting  to  this  direct  method  of  suturing,  more  perfect  coaptation 
is  secured.  In  the  case  of  large  nerves,  it  is  advisable  to  reenforce  the  direct 
sutures  with  a  number  of  paraneural  sutures.  The  best  material  for  the  su- 
tures is  aseptic  catgut.  An  ordinary  sewing-needle  with  a  dull  point  is  pref- 
erable to  a  surgical  needle,  as  it  is  more  sure  to  pass  through  the  nerve 
without  injuring  the  fibres. 

From  one  to  three  direct  sutures,  according  to  the  size  of  the  nerve,  are 
applied,  and  from  three  to  six  paraneural  sutures.  The  needle  is  passed 
straight  through  the  nerve  on  each  side,  one-eighth  to  one-fourth  of  an  inch 
from  the  ends,  and  care  must  be  exercised,  in  tying  the  sutures,  to  bring  the 
cut  surfaces  in  accurate  apposition,  and  not  to  tie  the  sutures  too  tightly. 


DircctSutare 


Fara-neural 
i'lUure 


Fig.  52.— Nerve-suture,  showing  Application  of  Direct  and  Paraneural  Sutures. 

as  by  doing  so  the  nerve-ends  are  liable  to  become  displaced  by  overlapping. 
In  tying  the  paraneural  sutures  the  necessary  precautions  must  be  taken  to 
prevent  the  margins  of  the  sheath  from  insinuating  themselves  between  the 
nerve-ends. 

Primary  Nerve-suture. — A  primary  nerve-suture  is  one  used  to  unite 
a  nerve  immediately  or  soon  after  the  injury  has  occurred,  and  before  any 
degenerative  changes  have  taken  place.  It  should  always  be  resorted  to  in 
the  treatment  of  accidental  wounds  where  one  or  more  nerves  have  been 
divided,  also  where  in  operations  a  nerve  has  been  divided  accidentally,  and, 
finally,  in  cases  where  a  neurectomy  for  pathological  conditions  cannot  be 
avoided.  The  results  after  primary  suture  have  been  very  satisfactory. 
Bruns  has  collected  71  cases  from  different  sources,  and  in  more  than  33  per 
cent,  of  the  number  function  was  restored.  As  suppuration  in  a  wound  where 
a  nerve  has  been  sutured  would,  in  all  probability,  cause  tearing  out  of  the 
sutures  and  displacement  of  the  nerve-ends,  it  is  of  the  greatest  practical 


76  PRINCIPLES    OF    SUEGERY. 

importance  to  secure  for  such  wounds  an  aseptic  condition  and  to  obtain 
primary  union  throughout,  and  consequently  no  provision  for  drainage 
should  be  made.  If  the  wound-surfaces  cannot  be  approximated,  and  a 
greater  or  less  space  has  to  fill  up  by  granulation,  a  bundle  of  catgut-threads 
can  be  used  for  a  capillary  drain,  in  order  to  avoid  tension  from  the  accu- 
mulation of  blood  or  the  primary  wound-secretion. 

Secondary  Nerve-suture. — When  a  divided  nerve  fails  to  unite,  the  ends 
become  bulbous,  are  usually  found  imbedded  in  a  mass  of  cicatricial  tissue, 
and  separated  from  each  other  from  one  to  two  or  more  inches.  The  bulb- 
ous enlargement  of  the  proximal  end  remains  permanently  and  is  often  a 
useful  guide  to  the  nerve  in  cases  requiring  secondary  nerve-suture.  Func- 
tion below  the  point  of  division  is  completely  lost;  the  distal  portion  of  the 
nerve  itself,  being  no  longer  in  connection  with  the  central  nervous  system, 
undergoes  degeneration,  and  the  muscles  supplied  by  the  injured  nerve  be- 
come atrophic  and  useless.  The  reuniting  of  such  a  nerve  is  done  by  the 
secondary  suture.  Experience  has  shown  that  function  can  be  restored  by 
this  procedure  years  after  the  injury.  Jessop  vivified  the  nerve-ends  and 
applied  sutures  nine  years  after  injury  of  the  median  nerve,  and  restored 
function.  Langenbeck  sutured  the  sciatic  nerve  two  years  after  division; 
sensation  returned  in  three  days,  and,  later,  motion.  As  a  rule,  sensibility 
returns  first  after  nerve-suture,  followed  considerably  later  by  restoration 
of  motor  function.  The  most  speedy  restoration  of  function,  both  sensory 
and  motor,  after  secondary  suture  is  reported  by  Tillaux.  He  operated  on 
the  median  nerve  three  years  after  division.  The  ends  were  found  imbedded 
in  a  cicatrix  and  separated  from  each  other  four  centimetres.  The  ends 
were  vivified  and  sutured.  He  claimed  that  physiological  function  was  re- 
stored completely  three  hours  after  the  operation.  There  can  be  no  doubt 
of  the  ultimate  recovery  of  nerve-function  in  this  case,  but  that  this  should 
have  been  attained  in  three  hours  appears  next  to  impossible.  Enough  has 
been  said  to  show  that  secondary  nerve-suture  can  be  resorted  to  with  good 
prospects  of  success  years  after  an  injur}'-,  but  for  well-known  reasons  it 
should  not  be  postponed  after  it  has  become  evident  that  union  has  failed 
to  take  place.  Unnecessary  delay  is  dangerous,  because  when  a  nerve  has 
become  permanently  disconnected  from  the  central  nervous  system  muscular 
degeneration  goes  hand  in  hand  with  degeneration  of  the  distal  portion  of 
the  nerve,  and,  the  longer  the  operation  is  delayed,  the  greater  the  length 
of  time  required  to  complete  the  regeneration  of  the  nerve  and  the  muscles. 
The  first  secondary  nerve-suture  was  made  by  ISTelaton  in  1865.  In  Ger- 
many the  first  operation  was  made  by  Gustav  Simon  in  1876,  and  he  was 
followed  by  Langenbeck  the  following  year.  In  1884  Bruns  found  33  re- 
corded cases,  and  in  24  of  this  number  the  result  was  satisfactory.  As  a 
rule,  sensation  returned  srraduallv  in  from  two  to  four  weeks,  while  motion 


NEEVE-SUTUKE.  77 

did  not  return  nntil  three  weeks  to  three  months  after  the  operation.  Com- 
plete restoration  of  function  was  seldom  completed  until  half  a  year  to  one 
year  after  the  operation.  As  in  cases  which  require  secondary  suture  the 
nerve-ends  are  sealed  with  a  mass  of  cicatricial  tissue,  it  is  always  necessary 
to  resect  the  ends,  after  which  the  sutures  are  applied  in  the  same  manner 
as  in  primary  nerve-suture.  Both  nerve-ends  must  be  freed  from  all  cica- 
tricial adhesions  before  approximation  is  attempted,  and,  if  this  cannot 
be  readily  done  on  account  of  previous  retraction,  both  ends  are  carefully 
stretched  and  sufficient  elongation  secured  so  as  to  prevent  any  tension  upon 
the  sutures.  A  great  deal  can  be  done  to  prevent  tension  by  placing  the 
limb  in  such  a  position  as  will  relax  the  nerve;  for  instance,  flexion  of  the 
hand  and  forearm  in  suturing  the  ulnar,  median,  or  musculo-spiral,  and 
flexion  of  the  leg  and  extension  of  thigh  after  reuniting  the  sciatic.  Th-e 
position  of  the  limb  most  favorable  for  the  union  of  a  sutured  nerve  is  best 
secured  by  a  plaster-of-Paris  dressing,  which  is  allowed  to  remain  not  only 
till  the  external  wound  is  healed,  but  until  the  nerve  has  firmly  united. 
When  a  nerve  has  suffered  a  considerable  loss  of  substance  at  the  seat  of  in- 
jury it  is  often  found  impossible  to  bring  their  ends  in  contact  by  nerve- 
stretching  and  position  of  limb,  and  in  such  cases  restoration  of  continuity 
becomes  an  exceedingly  difficult  task. 

Letievant  suggested  that  the  defect  in  such  cases  should  be  corrected 
by  a  neuroplastic  operation.  He  proposed  that  a  flap  should  be  taken  from 
each  end  sufficiently  long  that,  when  turned  toward  each  other,  they  could 
be  sutured  at  the  middle  of  the  defect,  thus  making  a  connecting  bridge  of 
nerve-tissue  between  the  separated  nerves.  (Fig.  53.)  As  could  be  expected, 
in  a  case  where  he  performed  this  operation  the  result  was  negative.  In  a 
case  operated  on  by  Tillmanns  after  this  method,  partial  restoration  of  func- 
tion was  established  three  and  a  half  months  after  the  operation.  The  suc- 
cess in  this  case  was  probably  not  the  result  of  conduction  of  nerve-force 
along  the  fibres  of  the  flaps,  but  the  production  of  new  fibres  across  the  gap, 
perhaps  through  the  tissues  composing  the  temporary  bridge.  The  same 
author  devised  for  a  similar  class  of  cases  what  he  calls  cross-sutures  (Fig. 
54),  where  the_  nerves  are  cut  at  a  different  level  and  the  ends  separated  too 
far  for  any  direct  method,  suitable  in  the  median  and  musculo-cutaneous  in 
the  arm  or  the  median  and  cubital  nerve  in  the  forearm.  The  two  longer 
ends  are  united  by  direct  suture  and  the  shorter  ones  grafted  into  the  ad- 
joining trunk.  The  success  of  this  operation  is  based  on  the  physiological 
law  of  the  conductibility  of  nerve-fibres.  This  operation  has  resulted  suc- 
cessfully in  a  number  of  instances  in  the  human  subject.  From  his  experi- 
ments on  animals,  Gluck  came  to  the  conclusion  that  nerve-defects  could 
be  corrected  by  transplantation  of  nerves;  that  is,  inserting  a  piece  of  nerve 
from  an  animal,  corresponding  in  size  to  the  nerve  to  be  reunited,  between 


78 


PEINCIPLES    or    SURGEEY. 


the  nerve-ends,  and  uniting  it  with  them  with  sutures.  He  reports  a  num- 
ber of  successful  experiments  on  chickens,  filling  the  gap  with  a  nerve  taken 
from  rabbits.  Phiiipeaux  and  Vulpian,  from  their  own  researches,  came  to 
the  conclusion  that  a  transplanted  nerve  alwa3^s  degenerates  and  disappears, 
and  that  restoration  of  structure  and  function  onh'  takes  place  by  regenera- 


f.  I 


Pig.  53.  Fig.  54. 

Fig.  53. — Neuroplasty.  A,  upper  end;  A',  lower  end;  H,  H',  flaps  turned  toward 
each  other;  D',  B',  suture  of  the  two  flaps;  B,  D,  level  of  section  of  flaps.  {After 
Letievant.) 

Fig.  54. — Cross-suture.  1.  The  ends  A  B  and  C  D  are  too  far  apart  to  be  sutured; 
the  upper  end  (0)  of  the  nerve  will  be  united  with  the  lower  end  (B)  of  the  other  nerve. 
2.  Completed  suture;  the  ends  A  D  are  implanted  into  the  adjoining  nerve-trunk.  {Till- 
manns.) 

tion  from  the  nerve-ends.  It  is  probable  that  the  methods  of  nerve-restora- 
tion devised  b}^  Letievant  and  Gluck  are  useful  in  reuniting  separated  nerve- 
ends  in  the  same  manner  as  the  suture  a  disla-iice  of  catgut  suggested  by 
Assaky.     The  interposition  of  an  aseptic,  absorbable  substance  like  catgut 


NEEVE-SUTURE.  79 

or  nerve-tissue  serves  as  a  temporary  scaffolding  for  the  products  of  tissue- 
proliferation  from  the  nerve-ends,  which  at  the  same  time  determines  the 
direction  for  the  new  material,  providing  the  shortest  route  to  meet  the  same 
material  from  the  other  side.  When  catgut  is  employed  two  or  three  sutures 
are  used,  so  that  the  combined  size  of  the  strings  will  at  least  approximately 
correspond  to  the  size  of  the  nerve.  Van  Lair,  who  believes  that  regenera- 
tion of  a"  nerve  takes  place  exclusively  from  the  proximal  end,  resected  a  piece 
of  the  sciatic  nerve  in  dogs,  and  then  sutured  both  ends  of  the  nerve  to  the 
ends  of  a  decalcified-bone  tube,  which  in  length  corresponded  to  the  section 
of  nerve  removed.  From  the  results  of  his  experiments,  ten  in  number,  he 
became  satisfied  that  continuity  of  the  nerve  was  restored  by  the  new  nerve- 
fibres  from  the  proximal  end  growing  into  the  tunnel,  bridging  the  defect  in 
a  comparatively  short  time,  as  they  had  no  resistance  to  overcome,  and 
uniting  with  the  end  of  the  nerve  on  the  opposite  side  of  the  tube.  It  ap- 
pears to  the  author  that  this  method  of  overcoming  the  difficulties  of  re- 
uniting nerve-ends  widely  apart  is  not  only  an  ingenious  procedure,  but,  if 
applied  in  practice,  promises  better  results  than  any  other  method  hereto- 
fore proposed.  In  certain  cases  where  the  distal  end  cannot  be  found,  or 
where  the  separation  is  so  great  that  none  of  the  methods  of  approximation 
so  far  devised  hold  out  any  inducements  of  a  successful  issue,  Letievant  sug- 
gested the  idea  of  grafting  the  central  end  upon  the  intact  trunk  of  a  neigh- 
boring nerve.  This  operation  failed  in  his  hands,  but  Tillaux  and  Tillmanns, 
slightly  modifying  the  method,  were  successful.  In  Tillmanns'  case  the 
ulnar  nerve  had  been  divided,  the  ends  were  found  separated  four  and  one- 
half  centimetres,  and  the  proximal  end  was  grafted  upon  the  median  nerve. 
Sensation  returned  in  a  month,  and  by  using  electricity  and  massage  recov- 
ery was  complete  a  year  later.  JSTerve-grafting,  as  advocated  by  Letievant, 
should  only  be  resorted  to  after  implantation  of  a  decalcified-bone  tube  be- 
tween the  nerve-ends  has  been  tried  and  proved  a  failure,  or  in  cases  where 
the  defect  is  very  extensive,  or,  finally,  if,  after  the  most  diligent  search,  the 
distal  end  cannot  be  found.  Eestoration  of  function  does  not  always  follow 
after  the  continuity  of  a  nerve  has  been  restored  by  operative  measures. 
Ehrmann  has  reported  such  a  case.  The  radial  nerve  was  divided  below  the 
elbow  and  failed  to  unite.  Complete  paralysis  of  all  the  muscles  supplied 
by  this  nerve.  After  the  lapse  of  seven  months  the  nerve  was  exposed,  and 
the  ends,  which  were  five  centimetres  apart,  were  vivified  and  sutured. 
Seven  months  after  the  operation,  no  improvement.  The  nerve  was  again 
exposed  at  the  former  site  of  operation,  and  it  was  found  that  union  had 
taken  place,  but  the  nerve  was  compressed  by  a  firm  cicatrix  two  or  three 
centimetres  in  length.  The  nerve  was  relieved  from  its  imprisonment,  and 
when  the  faradic  current  was  applied  all  the  muscles  supplied  by  the  nerve 
responded.     Pour  months  later,  complete  recovery.     This  case  reminds  us 


80  PEINCIPLES    OF    SURGERY. 

of  the  importance  of  securing  healing  of  tlie  nerve  and  wound  with  as  little 
cicatricial  tissue  as  possible,  wliich  can  only  be  done  by  absolute  asepsis  and 
careful  attention  to  suturing  of  the  wound. 


CHAPTER  III. 

Degeneeation.^ 

Degeneeatiox  is  the  counterpart  of  regeneration.  Regeneration  is  an 
active  cellular  process  which  results  in  the  formation  of  new  tissue  within 
normal  physiological  limits,  while  degeneration  consists  of  cell-changes 
which  lead  to  atrophy  or  complete  destruction  by  processes  in  which  the 
protoplasm  of  the  cells  takes  no  actiTC  part.  Regeneration  is  an  active  build- 
ing-up process  in  which  the  products  of  tissue-proliferation  are  utilized  in 
the  formation  of  new  tissue  or  in  replacing  tissue  destroyed  by  injury  or  dis- 
ease. On  the  other  hand,  degeneration  consists  in  the  waste  or  destruction 
of  existing  tissue  by  inadequate  nutrition  or  noxious  extrinsic  influences 
which  destroy  cell-life  and  activity.  It  is  proper  that  the  subject  of  degen- 
eration should  be  discussed  after  the  student  has  familiarized  himself  with 
the  nature  and  histology  of  regeneration  and  before  he  begins  to  study  the 
complicated  processes  which  characterize  inflammation,  and  because,  in 
every  inflammation,  cell-destruction  is  a  constant  feature,  and  also  because 
there  is  no  inflammation  so  severe  but  what,  somewhere  in  the  infected  field 
or  in  its  periphery,  attempts  at  repair  can  be  seen. 

Regeneration  is  characterized  by  karyokinesis, — great  cell-activity; 
degeneration  by  nuclear  fragmentation,  karyolysis,  and  cell-destruction. 

ATEOPHY. 

The  simplest  form  of  degeneration  is  atrophy.  It  is  caused  by  defective 
nutrition.  It  may  be  limited  to  isolated  cells,  a  part,  or  organ,  or  may  impli- 
cate the  entire  body,  according  to  the  extent  of  the  etiological  influences.  As 
a  normal  condition,  it  is  seen  in  some  of  the  organs  of  the  body  after  periods 
of  high  physiological  activity,  and  is  then  known  as  involution- atrophy.  Gen- 
eral atrophy  attends  old  age,  and  follows  acute  and  wasting  diseases  and  any 
affections  which  interfere  with  digestion,  absorption,  and  assimilation  of  food 
or  defective  food-supph^  and  is  then  called  marasmus.  Atrophy  from  pro- 
longed non-use  is  termed  inactivity-atrophy.  It  is  seen  most  frequently  as 
one  of  the  constant  results  in  advanced  cases  of  joint  tuberculosis.  In 
atrophy  the  macroscopical  and  microscopical  changes  are  more  of  a  quanti- 
tive  than  qualitative  nature,  the  essential  etiological  feature  consisting  of  a 
defective  substitution  of  nutritive  material,  and  the  conditions  would  be  de- 


1  The   author  desires  to  acknowledge  his  indebtedness  to   Perls'    "Pathologie''   for  valu- 
able information  in  preparing  this  chapter. 


(81) 


82 


PKINCIPLES    or    SURGERY. 


scribed  more  correctly  if  the  term  aplasia  were  substituted  for  what  is 
usually  understood  and  described  as  atrophy.  The  atrophy  of  fat-tissue  pro- 
duced by  the  withdrawal  of  food  in  animals  has  been  studied  most  carefully 
by  Flamming,  who  ascertained  that  in  the  cells  deprived  of  their  fatty  con- 
tents in  this  manner  an  active  multiplication  of  nuclei  and  production  of 
young  cells  takes  place  whereby  a  microscopical  picture  is  created  which  very 
much  resembles  inflammatory  tissue.  Similar  observations  were  made  by 
Grawitz  and  his  pupils  in  atrophy  of  muscles  and  nerves.  Kolliker  regards 
the  giant  cells  in  the  myeloid  tissue  as  the  essential  agents  in  the  production 
of  atrophy  of  bone,  and  excavation  of  Howship's  lacunae  as  their  almost  spe- 
cific product.     Eustitzki  believes  that  these  cells  secrete  an  acid  substance 


Fig.   55.— Ischasmic   Paralysis  of   Muscles  of  Leg  Following   Degeneration   Produced   by 
Scar-contraction  after  an  Extensive  Burn.    Large  Circular  Ulcer  Remained  Unhealed. 


which  dissolves  the  earthy  constituents.  Atrophy  of  muscles  after  section 
of  the  motor  nerves,  with  or  without  fat-formation,  can  reach  a  consider- 
able degree  after  a  few  months.  On  the  other  hand,  muscle-degeneration 
and  atrophy  the  result  of  ischasmia  sets  in  within  a  very  few  days,  and 
leads  to  permanent  results,  as  has  .been  shown  by  Volkmann,  Leser,  and 
others.  This  form  of  muscle-atrophy  is  observed  most  frequently  in  conse- 
quence of  harmful  constriction  by  fixation  dressings  in  the  treatment  of 
fractures,  but  has  also  been  seen  as  a  remote  consequence  of  cicatricial  con- 
traction, more  especially  after  extensive  burns  of  the  extremities.  Muscle- 
degeneration  from  defective  blood-supply  is  better  known  under  the  term 
ischasmic  paralysis.  (Fig.  55.)  Progressive  hemiatrophy  of  the  face  is  gen- 
erally regarded  in  the  light  of  a  trophoneurotic  disturbance. 


CLOUDY    SWELLING.  83 


CLOUDY    SWELLING. 


Degenerative  changes  in  the  protoplasm  of  living  cells  depend  largely 
on  modifications  of  their  albuminous  contents.  It  is  difficult  to  determine 
in  individual  instances  whether  such  modifications  are  caused  by  chemical  or 
physical  influences.  Bacteriological  investigations  have  opened  up  a  wide 
field  for  investigation  in  this  direction,  as  it  is  now  Avell  known  that  many 
cell-degenerations,  both  of  the  acute  and  chronic  type,  are  caused  by  toxic 
substances  eliminated  from  pathogenic  bacteria.  In  most  of  the  acute  in- 
fective diseases  cell-degeneration  in  different  parts  of  the  body  is  a  constant 
feature  and  produced  solely  by  toxins  elaborated  in  the  tissues  or  brought  in 
contact  with  them  through  the  medium  of  the  general  or  lymphatic  circula- 
tion. The  most  frequent  form  of  retrograde  tissue-metamorphosis  is  the 
cloudy  swelling,  known  also  as  albuminous  infiltration  or  metamorphosis, 
granular  degeneration,  and  parenchymatous  degeneration. 

The  parenchyma-cells  are  usually  affected  by  this  form  of  degeneration, 
and  hence  the  designation  "parenchymatous  degeneration."  The  con- 
nective tissue,  if  affected,  does  not  show  the  pathological  conditions  as 
plainly.  The  organs  and  tissues  the  seat  of  cloudy  swelling  are  somewhat 
enlarged,  softened,  pale,  and  of  a  dirty-gray  color;  the  normal  outlines  of 
glandular  structures  obscured,  and  the  transparency  of  the  tissues  is  dimin- 
ished. Under  the  microscope  the  cells  exhibit  a  granular  appearance;  the 
granules  are  very  fine,  refract  light  feebly,  and  impart  to  the  cell-protoplasm 
a  dusty,  cloudy  appearance,  which,  in  the  muscle-fibre,  for  instance,  obscures 
the  nuclei  and  striations.  The  cells  are  enlarged,  their  form  irregular,  and 
outlines  ill  defined.  Acetic  acid  clears  up  the  protoplasm,  and  the  nuclei 
become  more  distinct.  The  granules  are  degenerated  albuminous  products, 
which  are  dissolved  by  the  acetic  acid.  Cloudy  swelling  is  constantly  seen 
in  acute  infectious  diseases,  phosphorus  poisoning,  and  catarrhal  infiamma- 
tion.  Cloudy  swelling  often  precedes  fatty  degeneration,  cell-death,  or  also 
proliferation. 

Virchow,  who  first  described  cloudy  swelling,  found  it  during  the  early 
stage  of  parenchymatous  infiammation.  It  was  discovered,  however,  later, 
that  in  most  instances  it  is  present  in  patients  the  subjects  of  acute  infectious 
diseases,  in  organs  which  were  not  the  seat  of  inflammation.  The  textural 
changes  in  the  protoplasm  of  the  cells  point  either  to  an  increased  supply 
of  albuminoid  substances  or  a  modification  (coagulation)  of  the  existing 
cell-contents  into  a  less  soluble  substance.  It  is  very  probable  that  in  inflam- 
mation the  former  and  in  acute  infectious  diseases  the  latter  process  takes 
place.  The  destructive  effect  of  toxins  on  cells  is  well  known,  and  we  can 
safely  assume  that  the  degree  of  parenchymatous  degeneration  is  determined 
largely  by  the  amount  and  virulence  of  the  toxins  which  are  brought  in  con- 


84  PEINCIPLES    OF    SUKGEKY. 

tact  with  the  cells,  in  this  respect  resembling  the  toxic  effects  of  phos- 
phorus. 

FATTY    DEGENERATION. 

An  advance  in  the  regressive  metamorphosis  of  cloudy  swelling  leads 
to  fatty  degeneration.  In  fatty  degeneration  the  contours  of  the  granules 
are  more  sharply  defined,  the  dusty  appearance  is  changed  into  a  dotted 
field,  the  groups  of  molecules  appear  clear  and,  when  dense,  present  an  al- 
most black  appearance.  (Fig.  56.)  These  granules  are  not  altered  albumen, 
but  fat,  which  takes  the  place  of  albumen.  In  acetic  acid  the  normal  cell- 
contents  are  cleared  up,  but  the  granules  remain  unchanged;  hence,  can  be 
seen  more  distinctly.  These  fat-molecules  are  soluble  in  ether.  The  gran- 
ules vary  much  in  size,  those  of  medium  size  corresponding  with  the  red 
blood-corpuscles.  If  the  degeneration  is  far  advanced,  these  granules  co- 
alesce into  larger  masses,  and  crystals  make  their  appearance.    As  the  cells 


Fig.  56. — Fatty  Degeneration  of  the  Heart-muscle  in  Pernicious  Anaemia.    Fat  Stained 
Blaclc  with  Osmic  Acid.    A,  fat-droplets. 

and  tissues  involved  in  the  fatty  degeneration  are  not  increased  in  size  we 
have  no  reason  to  assume  that  preformed  fat  was  supplied,  but  are  forced  to 
the  conclusion  that  it  is  an  intracellular  product.  In  degenerative  lipogene- 
sis  the  fat  is  probably  formed  from  the  constituents  of  the  cell,  which  suffers 
grave  protoplasmic  and  nuclear  lesions.  Lindemann  takes  it  for  granted  that 
fat  can  form  from  albumen,  although  Pfliiger,  Eosenfeld,  and  others  take  an 
opposite  view.  Lindemann  lays  stress  on  the  formation  of  fats  from  pro- 
teids  by  bacteria,  as  is  supposed  to  be  the  case  in  the  production  of  adi- 
pocere,  and  which  might  therefore  occur  in  infections.  As  pointed  out  by 
Taylor,  even  though  we  admit  that  fat  is  formed  in  degenerated  cells,  it  can 
still  be  claimed  that  it  is  a  chemical  product  from  carbon  compounds — sugar, 
glycogen,  glucosides,  and  mucin — which  abound  in  cells  rather  than  from 
the  proteids:  a  contingency  which  Lindemann  does  not  consider  suifi- 
ciently.  Occasionally  fatty  degeneration  is  associated  with  the  formation  of 
a  substance  which  resembles  the  coagulated  medulla  of  nerves  (myelin  de- 
generation).   This  combination  of  degenerative  processes  is  seen  most  fre- 


FATTY    DEGENERATION".  85 

quently  in  the  alveoli  of  the  lungs.  This  substance  is  probably  liberated 
lecithin,  which,  when  dissolved  in  water,  assumes  the  myelin  form.  If  the 
fatty  degeneration  is  far  advanced  and  extensive,  a  mass  is  formed  composed 
of  free  fat-globules,  remnants  of  protoplasm,  and  nuclei,  which  is  known  as 
fatty  detritus.  In  old  deposits  of  this  kind  fat-crystals — so-called  margaric- 
acid  needles — make  their  appearance.  Besides  these  delicate  soft  crystals 
plates  of  cholesterin  isolated  and  in  masses  mark  the  advanced  stage  of  the 
degenerative  process.  Fatty  degeneration  is  a  very  frequent  tissue-change. 
All  those  causes  which  have  been  enumerated  in  connection  with  simple 
atrophy  and  cloudy  swelling  produce  fatty  degeneration;  very  often  we 
find  the  latter  side  by  side  with  the  two  first  conditions  and  occasionally 
all  coexist  at  the  same  time.  A  mild  form  of  fatty  degeneration  con- 
stantly takes  place  in  most  of  the  tissues  as  an  expression  of  the  con- 
stant changes  incident  to  the  substitution  of  new  for  old  cells,  and  in  the 
aged  it  is  almost  constantly  found  in  the  intima  of  the  large  blood-vessels, 
as  well  as  in  the  walls  of  the  small  arteries  of  the  brain,  and  occasionally  also 
in  the  parenchyma-cells  of  the  organs  which  undergo  atrophy.,  As  a  patho- 
logical process  we  find  fatty  degeneration,  in  the  first  instance,  as  a  local 
affection  limited  to  certain  parts  of  the  body,  and,  in  the  second  place,  as 
an  acute  and  diffuse  lesion  involving  different  organs  and  tissues.  The 
localized  form  is  caused  either  by  a  defective  blood-supply  like  simple  atro- 
phy, or  increased  tissue-destruction  with  impaired  resorption  and  imperfect 
restitution,  caused  either  by  a  disproportion  between  action  and  rest,  by 
impairment  of  the  blood-  and  lymph-  circulation,  by  ferment — or  similar 
infiuences  which  are  destructive  to  the  cell-contents.  Inflammatory  proc- 
esses are  frequently  the  direct  cause  of  quite  extensive  fatty  degeneration 
of  the  fixed  tissue-cells,  but  more  particularly  of  the  cells  in  the  exudate 
derived  either  by  cell-migration  or  proliferation.  After  nerve-section  fatty 
degeneration  takes  place  in  the  peripheral  end.  Eight  to  ten  days  after 
section  of  a  nerve  the  homogeneous  medullary  substance  around  the  axis- 
cylinder  breaks  up  into  irregular  clumps  varying  in  size,  which  in  a  few  days 
become  smaller  and  present  the  appearance  of  droplets  of  fat,  which  dis- 
appear slowly;  so  that  after  about  two  months  only  the  axis-cylinder  and  the 
collapsed  neurilemma  remain.  Of  the  greatest  interest  are  those  obscure 
cases  in  which  acute  fatty  degeneration  takes  place  simultaneously  in  sev- 
eral organs.  In  acute  infectious  diseases  the  cloudy  swelling  is  not  infre- 
quently followed  by  fatty  degeneration.  In  other  cases  of  acute  diffuse  fatty 
degeneration  attended  by  icterus  and  punctiform  ecchymoses  poisoning  with 
phosphorus  or  arsenic  was  shown  to  be  the  cause  of  death.  It  is  in  such 
cases  that  the  parenchyma-cells  of  the  liver  exhibited  in  a  most  marked  man- 
ner the  condition  known  as  fat-infiltration.  The  same  condition  is  found 
in  acute  atrophy  of  the  liver.    Acute  fatty  degeneration  of  different  organs 


86  PRINCIPLES    OF    SUEGERY. 

with  punctiform  extravasation  of  blood  has  also  been  found  in  connection 
with  progressive  pernicious  ansemia;  the  organs  principally  involved  were 
the  heart  and  blood-vessels.  Although  fatty  degeneration  and  fat-infiltra- 
tion resemble  each  other  in  many  respects,  they  constitute  two  different 
pathological  processes.  By  fat-infiltration  is  understood  the  deposition  of 
preformed  fat  in  the  tissues,  while  in  fatty  degeneration  the  fat  is  produced 
from  the  cell-contents  by  the  conversion  of  the  protoplasm  into  fat.  The 
latter  takes  place  when  the  organ  is  supplied  with  an  excess  of  fat  or  when 
the  existing  fat  fails  to  disappear  by  normal  processes  which  regulate  the 
supply  and  waste  of  this  constituent  of  the  body.  The  artificial  fattening 
of  animals  furnishes  a  good  illustration  of  what  we  mean  by  fat-infiltration. 
In  some  animals — especially  the  domestic  goose — thus  treated  the  liver  be- 
comes the  principal  depot  for  the  deposition  of  the  surplus  fat.  In  contra- 
distinction to  the  liver  the  seat  of  fatty  degeneration,  in  fat-infiltration  the 
organ  becomes  very  much  enlarged,  the  capsule  tense,  anterior  border  thick 
and  rounded,  and  the  parenchyma  fragile.  The  cells  are  filled,  not  with 
granules,  but  large  droplets  of  fluid  fat  densely  crowded  together.  The 
amount  of  fat  in  fat-infiltration  is  much  greater  than  in  fatty  degenera- 
tion. For  instance,  in  fatty  degeneration  of  the  heart  the  fat  seldom  ex- 
ceeds one-fourth  of  the  heart  in  weight,  while,  on  the  other  hand,  in  fat- 
infiltration  it  often  reaches  one-half  to  four-fifths. 

MUCOID,    COLLOID,    AND    WAXY    DEGENERATION. 

Mucin  is  a  degenerative  product  of  the  protoplasmic  contents  of  cells. 
This  substance  is  characterized  by  its  intrinsic  properties  to  absorb  water  to 
an  unusual  extent.  Filtration,  even  when  much  diluted,  is  exceedingly  dif- 
ficult, and  the  apparent  solution  is  exceedingly  viscid  and  can  be  drawn 
out  into  fine  threads.  It  differs  from  other  albuminous  substances  in  that 
on  the  addition  of  acetic  acid  it  is  precipitated  in  the  form  of  white  flakes 
which,  on  adding  an  excess  of  acetic  acid,  are  not  dissolved;  if  it  is  precipi- 
tated by  alcohol,  it  appears  under  the  microscope  usually,  not  in  the  form 
of  granules,  but  as  a  fine  fibrillated  deposit,  and  is  free  from  sulphur.  It  is 
this  substance  which  imparts  to  the  different  mucous  secretions  their  viscid 
property.  It  is  found  also  in  a  normal  condition  in  the  vitreous  humor  of 
the  eye  and  in  the  umbilical  cord.  As  a  pathological  product  we  find  mucin 
in  cells  as  well  as  in  the  intercellular  substance.  In  the  former  as  a  quan- 
titative increase  of  the  physiological  metamorphosis  in  catarrhal  and  inflam- 
matory affections  of  the  mucous  membranes,  the  mucous  glands  are  en- 
larged and  filled  with  mucin-globules;  their  cells  are  also  greatly  swollen 
by  the  accumulation  of  mucin;  others  rupture  and  are  destroyed.  In  the  in- 
tercellular substance — especially  that  of  cartilage  and  bone — also  in  tumors 


MUCOID,    COLLOID,    AND    WAXY   DEGENEKATION.  87 

mucin-production  takes  place  occasionally  in  inflammatory  processes  as  well 
as  during  passive  conditions,  at  times  with  diminished  coherence  of  the  tis- 
sue; so  that  a  mucoid  softening  takes  place;  this  softening  can  increase 
until  liquefaction  ensues,  with  the  formation  of  cysts  filled  with  a  mucoid 
substance  and  detritus  of  cells. 

An  exclusively  pathological  product,  the  result  of  degeneration,  is 
what  is  known  and  described  as  colloid  substance.  It  differs  from  mucin" 
in  being  more  consistent  and  presents  itself  macroscopically  in  the  form  of 
boiled  sago  with  at  times  a  yellowish  tint  of  color.  The  jelly-like  substance 
is  not  affected  by  alcohol  and  acetic  acid.  The  colloid  degeneration  of  cells 
is  very  similar  to  the  mucoid,  the  same  droplet  formation  in  the  protoplasm, 
only  that  the  globules  are  firmer;  but  it  appears  that  the  colloid  masses  can 
form  in  albuminoid  fiuids  independently  of  cell-activity.  The  thyroid 
gland  is  the  organ  which  exhibits  most  frequently  colloid  masses  in  greatest 
amount,  and  miasmatic  struma  consists  largely  of  a  distension  of  its  follicles 
with  honey-like  homogeneous  masses.  x\ccording  to  VirchoAv,  the  colloid 
substance  is  not  the  product  of  cell-transformation,  but  it  represents  the 
inspissated  fluid  rich  in  sodic  albuminate  transuded  into  the  follicles.  Col- 
loid formation  also  takes  place  in  the  parotid,  prostate,  and  ovaries.  The 
surface  of  the  masses  is  covered  by  epithelial  cells,  and  in  the  middle  of  the 
substance  besides  remnants  of  epithelial  cells  will  be  found  granules  of  albu- 
men and  fat  and  often  drops  of  a  thinner  fluid.  In  the  course  of  time  the 
colloid  substance  becomes  firmer  and  more  brittle.  Mucoid  and  colloid  de- 
generation are  often  seen  side  by  side,  especially  in  tumors  and  cysts,  often 
combined  with  other  regressive  metamorphoses. 

Eecklinghausen  has  described  a  degenerative  process  under  the  name 
hyaline  degeneratio.n  which,  in  some  respects  at  least,  differs  from  colloid 
degeneration.  The  hyaline  substance  differs  from  the  colloid  material  in 
that  it  can  be  stained  in  acid  fuchsin  and  eosin  and  resists  water,  alcohol, 
acids,  and  ammonia;   and  from  amyloid  as  it  does  not  react  to  iodine. 

Hyaline  degeneration  affects  different  organs  and  epithelial  cells  as  well 
as  connective  tissue.  Hyaline  masses  and  thrombi  were  found  by  Manasse  in 
the  vessels  of  the  brain  in  acute  infectious  diseases.  Transformation  of 
striated  muscle-fibres  into  a  fragile  homogeneous  shining  substance  anal- 
ogous to  colloid  masses  occurs  quite  frequently.  Zenker  described  this 
change  first  in  1864,  and  called  attention  to  its  constant  occurrence  in  ab- 
dominal typhus.  The  lower  ends  of  the  abdominal  recti  and  the  adductors 
are  most  frequently  affected,  and  it  is  here  where  the  degeneration  is  most 
extensive.  In  many  of  the  fibres  the  degeneration  is  most  extensive,  in 
others  it  is  localized.  The  striations  disappear  entirely  and  the  fibre  is 
transformed  into  a  structureless  mass  interspersed  with  a  granular  detritus, 
and  is  permanently  destroyed.     Zenker  describes  this  change  as  a  peculiar 


88  PEINCIPLES    OF    SUKGERY. 

form  of  waxy  degeneration.  The  same  change  has  been  also  found  in  other 
acute  febrile  affections  and  it  has  been  suggested  that  the  degeneration 
might  be  the  result  of  rupture  of  the  muscle-fibres.  Maier  and  Perls  have 
seen  colloid  degeneration  of  the  muscular  fibres  of  the  stomach  and  intes- 
tinal canal. 

AMYLOID    DEGENERATION". 

Under  the  term  of  corpora  amylacea  and  amyloid  substance  we  include 
substances  which,  like  the  colloid  material,  have  an  homogeneous,  faintly- 
shining  appearance  and  which  likewise  resist  chemical  reagents,  but  which 
differ  from  the  products  of  degeneration  already  described  by  its  peculiar 
behavior  toward  iodine  and  some  of  the  stains.  Like  starch,  the  amyloid 
substance  is  stained  a  beautiful  blue  or  brown  color  on  the  addition  of  iodine. 
If  the  substance  is  stained  brown  the  color  is  converted  into  greenish-blue 
color  if  sulphuric  acid  or  chloride  of  zinc  is  added.  In  aged  men  amyloid 
granules  are  found  in  the  prostate  which  react  to  iodine  specifically.  These 
minute  round  bodies  present  a  concentric  structure,  in  the  centre  of  which 
occasionally  a  detritus  of  cells  is  found.  Their  consistence  is  variable,  but 
they  are  always  brittle.  If  exposed  to  iodine,  some  of  them  stain  a  deep 
blue  in  a  few  minutes,  others  bluish-green  or  brown,  while  others  do  not 
stain  at  all,  showing  that  the  reaction  to  iodine  is  influenced  by  inorganic 
constituents  and  modified  albumen.  In  other  organs  smaller  granules  of  a 
similar  structure  and  composition  are  found;  a  constant  location  for  these 
bodies  is  the  ependyma  of  the  ventricles  of  the  brain  and  the  acoustic 
nerve  and  in  those  pathological  conditions  of  the  central  nervous  system 
in  which  increase  of  connective  tissue  is  followed  by  a  corresponding  increase 
of  the  parenchyma.  These  granules  are  paler  than  the  myelin  drops  from 
which  they  are  probably  formed.  Concentrated  sulphuric  acid  increases 
the  staining  properties  of  iodine.  Amyloid  bodies  are  frequently  found 
in  the  lungs,  also,  especially  in  hsemorrhagic  infarcts.  Similar  bodies  are 
sometimes  found  in  cartilage,  especially  in  the  intervertebral  cartilages 
in  a  state  of  inflammation,  and  occasionally  they  are  seen  in  diverse  other 
tissues,  such  as  cicatrices  of  the  skin,  phlebolites,  and  tumors.  While 
the  instances  mentioned  above  represent  a  localized  form  of  degeneration 
and  without  much  pathological  importance,  there  is  a  diffuse  process 
which  is  known  as  amyloid  degeneration  of  the  tissues  that  appears 
simultaneously  in  different  organs,  accompanied  by  anaemia  and  hydropic 
conditions:  a  frequent  cause  of  fatal  marasmus.  This  degeneration  mani- 
fests itself  under  the  microscope  in  the  form  of  swelling  of  different  tissues, 
especially  of  the  vessel-walls,  and  presents  itself  in  the  form  of  shining, 
vitreous,  homogeneous  masses,  which,  on  the  addition  of  iodine,  are  stained 
brown,  which  is  changed  into  a  greenish  blue  or  a  pure  blue  or  violet  if 


AMYLOID    DEGENERATION.  89 

acids  are  added.  Spleen,  kidneys,  liver,  and  lymphatic  glands  are  the  organs 
most  frequently  affected,  and  the  change  in  them  takes  place  in  a  definite 
part.  In  the  spleen  amyloid  degeneration  takes  place  in  two  distinct  forms. 
In  the  so-called  waxy  spleen  the  organ  is  much  enlarged,  firm,  inelastic, 
and  somewhat  doughy.  The  cut  surface  appears  uniformly  brownish  red, 
shiny,  unusually  transparent,  resembling  smoked  ham.  Iodine  stains  the 
surface  only  somewhat  deeper,  but  uniform,  so  that  the  change  is  not  very 
apparent.  Microscopical  examination  shows  that  the  capillary  spaces  are 
surrounded  by  a  narrow  zone  of  a  clear,  homogeneous  substance  to  which 
the  normal  or  endothelial  cells  which  have  undergone  fatty  degeneration 
are  attached.  In  the  other  form  of  amyloid  degeneration  of  the  spleen — 
the  so-called  sago  spleen — the  organ  is  softer  and  on  section  only  the  fol- 


U  36--     B 


Ct 


Fig.  57. — Amyloid  Degeneration  of  the  Kidney  Involving  the  Glomeruli  and  the  Capil- 
laries of  the  Cortex.  The  Amyloid  Material  has  been  Stained  Brown  with  Iodine.  Double 
knife  section.  From  a  case  of  chronic  pulmonary  tuberculosis.  X  75.  A,  capillaries 
showing  amyloid  degeneration.  B,  glomerulus  showing  amyloid  degeneration.  C,  large 
vessel  showing  amyloid  degeneration. 

licles  present  the  characteristic  changes  in  the  form  of  sago-like  structures, 
and  only  these  react  to  iodine,  and  in  them  the  blood-vessels  appear  as  yel- 
low dots  or  stripes.  In  the  amyloid  kidney  the  glomeruli  are  enlarged  and 
pale  and  on  the  addition  of  iodine  become  conspicuous  by  their  brown  color; 
very  often  the  vasa  recta  of  the  pyramids  are  also  found  much  degenerated 
and  react  intensely  to  the  iodine  stain.  In  the  liver  the  amyloid  degenera- 
tion begins  and  is  most  marked  in  the  centre  of  the  acini. 

The  villi  of  the  intestinal  canal  are  frequently  affected  by  amyloid  de- 
generation, while  the  mucous  membrane  over  Peyer's  patches  remains  intact. 
In  the  suprarenal  capsule  and  lymphatic  glands  the  cortical  layers  of  the 
parenchyma  are  principally  affected  and  exhibit  in  the  most  marked  manner 
the  reaction  to  iodine.    Examination  of  different  organs  which  have  under- 


90  PEINCIPLES    OF    SURGERY. 

gone  amyloid  degeneration  have  shown  that  different  tissue-elements  fur- 
nish the  amyloid  su.bstance.  Most  frequently  the  walls  of  the  small  blood- 
vessels are  primarily  affected,  and  in  these  the  change  is  first  observed  in 
the  media,  which  is  transformed  into  a  structureless  glassy  mass,  and  the 
thickening  of  the  walls  thus  caused  diminishes  the  lumen  of  the  affected 
vessels,  which  accounts  for  the  anemia  so  constantly  found  in  amyloid  or- 
gans. That  the  parenchyma-cells  can  undergo  amyloid  degeneration  can. 
be  best  seen  in  the  amyloid  follicles,  of  the  spleen  and  the  acini  of  the  amy- 
loid liver.  Diffuse  amyloid  degeneration  of  different  organs  is  most  fre- 
quently observed  as  a  remote  result  of  prolonged  suppuration  following  often 
tuberculosis  of  bones  and  joints  and  long-standing  empyema  and  old  cases 
of  syphilis.  It  is  more  than  probable  that  the  toxins  of  the  different  kinds 
of  pyogenic  microbes  play  an  important  role  in  the  etiology  of  diffuse  amy- 
loid degeneration,  which  appears  simultaneously  or  in  more  or  less  rapid 
succession  in  different  organs  in  the  course  of  chronic  suppurative  processes. 
The  different  forms  of  degeneration  which  have  been  described  are  of 
special  interest  to  the  surgeon,  as  he  is  often  in  a  position  to  prevent  such 
changes,  and  in  the  presence  of  some  of  them  he  recognizes  the  necessity  of 
abstaining  from  performing  major  operations  unless  called  for  by  emergen- 
cies which  leave  no  other  alternative.  Among  these  special  mention  must 
be  made  of  di^ffuse  amyloid  degeneration  and  fatty  degeneration  of  the  large 
blood-vessels,  with  and  without  calcification.  Timely  resumption  of  func- 
tion of  diseased  parts  or  organs,  massage,  and  electricity  are  best  calculated 
to  prevent  further  degeneration  and  restore  normal  nutrition  in  the  localized 
forms  of  degeneration,  more  especially  fatty  degeneration,  the  consequence 
of  prolonged  inactivity. 


CHAPTER  IV. 

Inflammation. 

The  subject  of  inflammation  is  one  of  deep  interest  both  to  the  student 
and  practitioner,  as  it  initiates  the  former  into  the  field  of  general  and  special 
pathology,  and  the  latter  meets  with  it  daily  in  some  form  in  his  practice. 
We  have  already  set  apart  from  inflammation  those  numerous  processes  by 
which  injuries  or  defects  are  repaired  without  destruction  of  any  of  the 
new  tissue-elements  which  have  been  described  in  the  flrst  chapter  under 
the  head  of  "Eegeneration."  From  a  scientific  and  practical  stand-point, 
it  is  exceedingly  important  to  draw  a  distinct  line  between  the  series  of 
tissue-changes  which  attend  regenerative  processes,  uncomplicated  by  the 
action  of  pathogenic  bacteria,  and  true  inflammation,  which  is  always  caused 
hy  the  presence  of  one  oi'  more  hinds  of  pathogenic  microbes.  As  compared 
with  true  inflammation,  it  has  been  customary  for  quite  a  number  of  years 
to  speak  of  regeneration  as  a  plastic  or  regenerative,  inflammatory  process; 
but  the  term  inflammation  ifi  the  future  should  be  limited  to  the  series  of 
histological  changes  which  ensue  in  the  living  body  from  the  presence  and 
action  of  specific  microorganisms,  while  the  word  regeneration  should  be 
used  to  designate  the  histological  changes  which  take  place  in  tissues  which 
have  been  primarily  in  an  aseptic  condition  or  have  been  rendered  so  after 
the  inflammation  has  subsided.  From  this  it  will  be  seen  that  the  study  of 
inflammation  is  intimately  and  inseparably  associated  with  a  consideration 
of  the  new  science  of  bacteriology.  For  most  forms  of  inflammation  the 
presence  of  a  specific  microorganism  has  been  demonstrated,  and  its  etio- 
logical relationship  established  by  cultivation  and  inoculation  experiments; 
and  in  the  few  inflammatory  diseases  where  no  such  positive  proofs  can  be 
furnished  we  have,  from  analogy  and  circumstantial  evidence,  reason  to 
suspect  the  presence  of  undiscovered  microbes.  Inflammation,  in  the  widest 
and  most  comprehensive  meaning  of  the  word,  should  be  made  to  embrace 
pathological  conditions  which  are  caused  by  the  action  of  pathogenic  mi- 
crobes or  their  toxins  upon  the  histological  elements  of  the  blood  and  the 
fixed  tissue-cells.  A  correct  definition  of  inflammation,  which  should  em- 
body the  etiological,  anatomical,  and  pathological  characteristics  of  the  dis- 
ease from  our  present  knowledge  of  the  subject,  cannot  be  given,  as  many 
important  points  connected  with  the  complicated  processes  await  explana- 
tion by  future  investigation.  Sanderson  defines  inflammation  as  "the  suc- 
cession of  changes  which  occur  in  a  living  tissue  ivhen  it  is  injured,  provided 
that  the  injury  is  not  -of  su^h  a  degree  as  at  once  to  destroy  its  structure  and 

(91) 


92  .  PRINCIPLES    OF    SURGERY. 

vitality."  As  we  have  restricted  the  term  inJElamniation  to  the  succession  of 
changes  which  occur  in  a  living  tissue  from  the  action  of  pathogenic  microbes 
or  their  toxins,  this  definition  would  cover  processes  which,  for  reasons 
already  given,  we  have  considered  as  instances  of  tissue-proliferation  un- 
attended by  any  of  the  characteristic  features  of  inflammation.  J.  Bland 
Sutton  uses  the  term  inflammation  in  a  more  restricted  sense  in  coining  the 
following  definition:  "It  is  the  method  hy  which  an  organism  attempts  to 
I'ender  inert  noxious  elements  introduced  from  without  or  arising  within  it." 
As  nothing  is  said  of  the  method,  the  most  important  part  of  the  definition, 
it  certainly  cannot  be  said  to  cover  the  whole  ground.  The  conception  of 
the  true  nature  of  inflammation  for  the  present,  at  least,  must  remain 
symptomatic.  As  a  rule,  inflammation  subsides  as  soon  as  the  primary 
cause  has  disappeared  or  has  been  rendered  inactive,  as  is  well  shown  by 
the  spontaneous  disappearance  of  febrile  disturbances  in  the  general  in- 
fective diseases,  and  the  subsequent  rapid  repair  of  the  local  lesions  which 
characterize  them.  If  an  acute  inflammation  become  chronic,  either  from 
a  diminution  of  the  quantitative  or  qualitative  intensity  of  the  primary 
cause,  or  from  the  tissues  becoming  accustomed  to  its  action,  it  is  sometimes 
difficult  to  tell  whether  the  primary  cause  has  disappeared  or  has  ceased 
to  act,  or  whether  it  is  still  present  and  active.  In  chronic  inflammation  the 
most  reliable  indications  of  the  presence  and  potency  of  the  primary  bac- 
terial cause  are  acute  exacerbations,  as  chronic  inflammation  only  consists 
of  a  series  of  acute  inflammatory  processes  which  repeat  themselves  at  longer 
or  shorter  intervals.  The  differences  between  an  acute  and  chronic  inflam- 
mation are  not  in  kind,  but  in  degree.  The  complicated  processes  which 
characterize  inflammation  can  be  studied  most  profitably  by  considering 
separately  and  conjointly  the  symptoms  to  which  they  give  rise,  which  Galen 
enumerated  as  calor,  rubor,  dolor,  et  tumor,  to  which  may  now  be  added  the 
functio  Icesa  of  modern  authors.  The  study  of  the  objective  and  subjective 
manifestations  of  inflammation  should  be  preceded  by  a  short  description 
of 

THE  HISTOLOGICAL  ELEMENTS  WHICH   ARE   DIRECTLY   CONCERNED   IN 
THE    INFLAMMATORY    PROCESS. 

In  a  very  recent  article,  the  veteran  pathologist,  Virchow,  makes  the 
statement  that  inflammation  is  not  a  uniform  process  with  constant  char- 
acteristics. He  recognizes  and  describes  four  distinct  varieties,  viz.:  1. 
Exudative.  2.  Infiltrative.  3.  Parenchymatous.  4.  Proliferative.  Each 
of  these  furnishes  different  products.  Infiammatory  hypergemia  is  a  prime 
factor  in  exudative  and  infiltrative  inflammations,  while  it  takes  a  secondary 
part  in  metamorphosing  and  the  proliferating  forms.  In  the  study  of  the 
complicated  processes  which  characterize  inflammation,  it  is  important  to 


HISTOLOGICAL    ELEMENTS    IN    THE   INELAMMATORY    PEOCESS.  93 

study  the  part  which  the  different  tissues  take  in  the  morbid  process.  The 
most  important  structures,  and  which  are  always  concerned  in  inflammation 
of  all  types  and  varieties,  are  the 

Capillary  Vessels. — The  most  important  histological  changes  in  inflam- 
mation, acute  or  chronic,  transpire  within,  and  in  the  immediate  vicinity 
of,  capillary  vessels.  The  smallest  arteries  and  veins,  the  vessels  on  either 
side  of  the  capillaries,  undergo  changes,  and  the  disturbance  of  circulation 
within  them  constitutes  a  part  of  the  picture  of  inflammation,  but  it  is  in 
the  capillaries  that  the  most  serious  disturbances  occur;    it  is  here  where 


Fig.  58.— Capillary  Vessels  of  the  Frog's  Mesentery,  Stained  with  Nitrate  of  Silver 
only;  the  "Wall  of  the  Vessel  is  Viewed  from  the  Surface,  and  is  Seen  to  Consist  of 
Elongated  Endothelial  Cells,  Marked  by  their  Outlines  only;  the  Nucleus  of  the  Indi- 
vidual Cells  is  not  Shown.  (Klein.) 

the  noxce  are  brought  in  closest  contact  with  the  paravascular  tissues,  and 
it  is  here  where  the  inflammatory  exudation  and  transudation  take  place. 
The  capillaries  are  minute  vessels,  or  rather  channels,  which  connect  the 
arteries  and  veins,  the  walls  of  which  are  composed  of  a  thin,  elastic,  endo- 
thelial membrane;  that  is,  a  single  layer  of  nucleated  cells  held  together 
by  an  amorphous  cement-substance.  In  silver-stained  specimens  the  cement- 
substance  appears  as  dark  lines  which  outline  the  boundaries  of  the  cells. 
The  shape  of  the  cells  is  more  or  less  elongated,  with  pointed  extremi- 
ties, and  their  outline  smooth  or  sinuous.  The  nuclei  of  these  cells  are  oval, 
situated  either  about  the  middle  of  the  cell  or  near  one  extremity.     The 


94  PEINCIPLES    OF    SUEGEEY. 

nucleus  contains  within  a  well-defined  membrane  a  net-work  of  chromatin 
threads^  but  no  nucleolus.  When  the  capillaries  undergo  alteration  and  dis- 
tension, as  in  inflammation,  the  cement-substance  yields  in  many  places; 
in  consequence  of  this  minute  openings  appear,  called  by  Arnold  stigmata, 
which  become  gradually  enlarged  into  stomata.  Winiwarter  found  that  by 
injecting  inflamed  capillaries  the  contents  of  the  vessel  escaped  through 
these  openings.  Through  these  openings  emigration  of  leucocytes  takes 
place,  and  when  the  inflammation  is  very  intense  the  red  corpuscles  escape: 
a  process  which  Strieker  has  named  diapedesis.  If  the  capillary  vessels, 
through  which  emigration  has  been  going  on,  be  stained  with  nitrate  of 
silver,  it  is  seen  that  the  emigration  is  limited  to  the  interstitial  cement- 
substance  of  the  endothelial  wall.     (Purves.) 

Klein  has  shown  that  the  walls  of  all  capillary  vessels  in  the  adult  state 
form  a  direct  connection  with  the  process  of  the  connective-tissue  corpuscles 
of  the  surrounding  tissue:   a  matter  of  great  interest  in  studying  the  rela- 


Fig.  59. — Leucocyte,  showing  Reticulum  of  Protoplasmic  Strings.     (Klein.) 

tionship  between  the  capillary  vessels  and  the  surrounding  connective-tissue 
spaces. 

Blood-corpuscles. — The  blood-corpuscles  frequently  serve  as  carriers  of 
the  microbic  cause  of  the  inflammation;  they  block  the  lumen  of  inflamed 
capillary  vessels,  partially  or  completely,  and  constitute  the  histological  ele- 
ments of  the  primary  exudation.  The  element  of  the  blood  which  is  more 
intimately  associated  with  the  histology  of  inflammation  is  the 

1.  Leucocyte,  or  "White  Blood-corpuscle. — This  is  a  nucleated,  spherical, 
transparent  mass  of  protoplasm,  without  a  limiting  membrane  or  envelope. 
Heitzmann  made  the  discovery  that  it'is  composed  of  a  reticulum  of  proto- 
plasmic strings,  with  a  hyaline  substance  in  the  meshes. 

The  nucleus  shows  a  similar  structure,  and  its  net-work  is  continuous 
with  that  of  the  cell-body.  Strieker  and  Klein,  as  well  as  a  number  of  other 
histologists,  have  adopted  Heitzmann's  views  in  reference  to  the  minute 
anatomy  of  the  leucocyte.  The  reticulated  structure  is  well  shown  by  stain- 
ing with  chloride  of  gold,  which  stains  the  protoplasmic  strings,  but  not  the 


HISTOLOGICAL    ELEMENTS    IN    THE    INFLAMMATOEY    PKOCESS. 


95 


interstitial  substance.  The  leucocyte  is  endowed  with  intrinsic  power  of 
locomotion, — amoeboid  movements,- — a  function  which  is  performed  by  the 
reticulum.  Wharton  Jones  discovered  motion  of  protoplasm  in  leucocytes 
of  human  blood  as  early  as  1846.  In  1862  Haeckel  showed  that  the  white 
blood-corpuscles  absorb  pigment-granules:  a  process  which  can  only  take 
place  by  amoeboid  movements,  which  by  change  of  form  of  cell  bring  the 
foreign  material  into  its  interior  by  inclusion.  These  observations  enabled 
Cohnheim  to  demonstrate  later  that  the  white  blood-corpuscles  found  in  the 
vascular  spaces  of  the  cornea  were  derived  from  the  blood;  in  other  words, 
to  establish  the  fact  of  emigration  of  leucocytes  through  the  inflamed  wall 
of  capillaries.  The  amoeboid  movements  of  the  colorless  corpuscles  can  be 
well  observed  for  hours  in  the  moist  chamber  on  the  warm  stage. 

The  movements  of  a  leucocyte  are  peculiar.     The  first  effort  consists 


Fig.  60. — Change  of  Forms  of  a  Moving  Leucocyte  by  Amceboid  Movements.     (_Elein.) 


of  a  protrusion  of  a  hyaline  film.  This  is  withdrawn  and  another  is  pro- 
truded; in  the  next  moment  this  is  diminished  to  a  very  minute  process, 
whereas,  on  the  opposite  side,  a  new,  broad  process  appears.  After  this  the 
corpuscle  is  seen  to  throw  out  processes  of  various  length  and  thickness,  and 
thus  to  alter  its  shape  in  a  considerable  manner.  By  virtue  of  the  amoeboid 
movement  of  leucocytes  they  move  from  place  to  place  independently  of 
the  blood-  or  plasma-  current.  This  independent  locomotion  enables  them 
to  pass  through  the  small  opening  in  the  wall  of  inflamed  capillaries,  and, 
after  they  have  reached  the  paravascular  tissues,  to  travel  along  connective- 
tissue  spaces  until  arrested  by  some  mechanical  obstruction.  If  pigment- 
material,  in  a  finely-divided  state,  is  mixed  with  blood,  either  before  or  after 
withdrawing  it  from  the  vessels,  the  projections  thrown  out  by  the  leuco- 
cytes inclose  the  particles  brought  in  contact  with  it,  and  the  granules  reach 


96  PEINCIPLES    OF    SUEGERY. 

in  this  manner  the  interior  of  the  leucocytes,  and  are  variously  distributed 
according  to  the  shape  and  movements  of  the  protoplasm.  Microbes  reach 
the  interior  of  the  leucocytes  in  the  same  manner.  In  cases  of  intravascular 
infection  the  emigration  corpuscles  convey  with  them  the  microbes  through 
the  wall  of  inflamed  capillaries  into  the  tissues  surrounding  them. 

Grawitz  certainly  underestimates  the  part  the  leucocytes  perform  in 
inflammatory  processes,  as  he  denies,  in  toto,  the  leucocytic  nature, — that  is, 
their  derivation  from  the  blood  in  exudates, — claiming  there  is  no  proof  in 
support  of  Cohnheim's  teachings.  He  does  not  consider  the  proliferation 
theory  of  Virchow  alone  in  cell-production.  His  own  view,  that  cells  arise 
from  the  intercellular  substance  and  from  cell-particles,  is  emphasized,  and 
is  called  " ScMummerzelUn  theory."  He  combats  the  teachings  of  Senftleben 
and  Leber,  who  claim  that  cells  formed  in  a  supposed  dead  cornea  introduced 
into  tissues  as  immigrated  cells.  He  claimed  the  corneal  tissue  was  not  dead, 
because:  (1)  cornea  was  removed  from  animal  several  days;  (3)  heating  to 
80°  C.  for  one-quarter  hour;  (3)  desiccation  of  tissue;  all  of  which  are  in- 
sufflcient,  in  his  opinion,  to  destroy  the  tissue.  If  such  tissue  is  introduced 
into  the  lymph-sac  of  frogs,  it  is  invaded  by  wandering  cells,  which  are  not 
immigrated  cells,  but  are  derived  from  the  corneal  tissue  itself.  In  dead 
corneal  tissue  (heating  to  53°  C.  or  immersion  in  sublimate  solution),  no 
wandering  cells  when  inserted  in  a  frog's  lymph-sac.  Ingenious  as  these 
experiments  may  appear,  they  do  not  militate  against  the  theory  that  leu- 
cocytes are  constantly  found  in  inflammatory  tissue,  and  perhaps  the  most 
important  proof  of  the  important  part  they  take  is  the  marked  leucocytosis 
which  is  always  found  during  all  acute  inflammatory  affections. 

2.  Red  Blood-corpuscle. — The  colored  blood-corpuscle  serves  less  fre- 
quently as  a  carrier  of  microbes  than  the  leucocyte,  as  it  does  not  possess  as 
active  amoeboid  movements.  For  the  same  reason  it  is  not  found  so  con- 
stantly as  a  component  part  of  the  inflammatory  exudation,  as  its  transit 
through  the  capillary  wall  is  a  more  passive  process,  and  is  accomplished 
principally  by  the  vis  a  tergo  in  case  the  stomata  are  suiSciently  large  to 
permit  its  passage.  Leonard  has  recently  demonstrated  the  amoeboid  move- 
ments of  the  red  corpuscles  by  instantaneous  microphotography.  The  move- 
ments extended  over  half  an  hour  upon  the  warm  stage,  and  the  pictures 
obtained  are  well  shown  in  Fig.  61.  The  presence  of  numerous  colored  cor- 
puscles in  the  exudation  is  an  indication  of  great  acuity  and  intensity  of  the 
inflammation:  conditions  causing  serious  and  extensive  alterations  of  the 
capillary  wall.  The  escape  of  whole  blood  through  a  capillary  vessel  greatly 
damaged  by  the  cause  of  the  inflammation  is  called  rliexis. 

3.  Third  Corpuscle. — A  third  cellular  element  in  the  blood,  the  third 
corpuscle,  was  discovered  by  Max  Schultze,  in  1865.  He  described  it  as  a 
small,  colorless  sphere,  or  granule.     Elaborate  descriptions  of  this  corpus- 


HISTOLOGICAL    ELEMENTS   IN   THE   INFLAMMATORY   PROCESS. 


97 


cle  were  given  by  Hayem^  in  1878,  and  Bizzozero,  in  1882.  Hayem,  from 
his  observations;,  believed  that  these  minute  structures  represented  young 
colored  blood-corpuscles,  and  hence  named  them  hsematoblasts.  Bizzozero 
entered  his  protest  against  this  theory  and  called  them  blood-plates  (Blut- 
pldttcJien).  Under  the  microscope  they  appear  as  minute,  faintly-colored 
blood-corpuscles.  They  seem  to  possess  a  little  stroma  like  the  red  blood- 
corpuscles,  but  contain  no  nucleus  and  are  devoid  of  any  cell-membrane. 
What  appears  as  a  nucleus  is,  according  to  Hayem,  an  optical  defect. 

Hayem  estimates  that  they  are  forty  times  more  numerous  in  man  than 
the  leucocytes,  and  twenty  times  more  abundant  than  the  colored  corpuscles. 
As  there  has  been  no  positive  proof  furnished  that  the  third  corpuscle  is  an 
embryonal  red  blood-corpuscle,  and  as  it  has  been  shown  that  blood-corpus- 
cles are  produced  from  the  fixed  cells  of  blood-producing  organs,  as,  for  in- 
stance, the  spleen  and  medullary  tissue,  it  is  advisable  not  to  apply  to  it  the 


Fig.  61. — AmcEboid  Movements  of  Red  Blood-corpuscles.     (After  Leonard.) 


term  hgematoblasts,  but  to  distinguish  it  from  the  remaining  two  morpho- 
logical elements  of  the  blood  numerically  by  calling  it  the  third  corpuscle. 
Under  a  higher  power  the  third  corpuscle  can  be  readily  recognized  in  the 
blood-stream  of  capillary  vessels  in  the  mesentery  or  web  of  a  frog.  In  blood 
withdrawn  from  a  vessel  it  is  destroyed  as  soon  as  coagulation  sets  in;  hence 
it  disappears  almost  immediately  after  it  leaves  the  blood-vessel.  In  order 
to  study  it  outside  of  the  body,  means  must  be  employed  to  prevent  coagula- 
tion, which  can  be  done  by  mixing  the  blood  with  the  following  solution, 
recommended  by  Hayem: — 

Distilled  water  200.00  cubic  centimetres. 

Sodic  chloride   1.00  gramme. 

Sodic  sulphate 5.00  grammes. 

Mercury  bichloride 0.50  gramme. 

From  a  needle-puncture  the  blood  is  allowed  to  mix  with  the  solution 
in  the  proportion  of  about  1  to  20  up  to  1  to  10-0.    In  this  mixture  the  third 


98 


PEINCIPLES    OF    SURGERY. 


corpuscle  will  retain  its  shape  and  size  for  twelve  to  twenty-four  hours.  The 
third  corpuscle  is  a  fibrin-producing  structure,  and,  as  such,  it  takes  an  active 
part  in  the  formation  and  growth  of  intravascular  blood-clots.  The  white 
mural  thrombus,  produced  intra  vitam,  is  composed  almost  exclusively  of 
this  element  of  the  blood.  If,  from  a  trauma  or  disease,  the  endothelial 
lining  of  a  blood-vessel  is  injured  and  the  smooth  surface  becomes  uneven, 
the  third  corpuscles,  floating  in  the  peripheral  portion  of  the  axial  current. 


Fig.  62. — 1.  Third  corpuscle.  A,  natural  appearance  when  seen  on  surface  and  on 
edge;  B,  C,  C",  D,  and  E,  appearance  presented  by  them  during  coagulation.  2.  Shows 
the  little  heaps  of  granules  formed  by  them  after  coagulation  (Hayem).  3.  A  small  blood- 
vessel as  stasis  is  approaching.  A,  third  corpuscles  in  periphery  of  stream;  B,  colored 
blood-corpuscles;    C,  leucocyte.     (Eljerth  and  Schimvielhusch.) 

come  in  contact  with  projecting  points,  and  are  arrested  and  become  attached 
to  the  vessel-wall,  layer  after  layer  is  added,  and  in  this  manner  the  mural 
thrombus  is  formed.  On  the  surface  of  recent  wounds  they  appear  in  large 
numbers,  lose  their  fibrin-ferment,  and  give  rise  to  the  formation  of  fibrin, 
which  acts  both  as  an  hsemostatic  and  temporary  cement-substance.  In  in- 
flammation the  third  corpuscle  escapes  through  the  capillary  wall  in  the 
same  manner  as  the  red  corpuscles,  but,  on  account  of  its  smaller  size,  its 
peripheral  location  in  the  blood-stream,  and  its  greater  abundance,  it  is 
numerically  more  abundant  in  the  inflammatory  exudation.  The  fibrin  in 
inflamed  tissues  is  undoubtedly  derived  largely  from  this  source. 

4.  Fixed  Tissue-cells. — The  flxed  tissue-cells  behave  differently  in  the 
inflamed  part,  according  to  the  intensity  and  nature  of  the  primary  mi- 


HISTOLOGICAL    ELEMENTS    IN    THE   INFLAMMATOEY    PROCESS.     "         99 

crobic  cause.  The  microbes,  or  their  ptomaines,  may  possess  such  intense 
local  toxic  properties  as  to  destroy  their  vitality  directly,  when  the  inflam- 
mation results  in  necrosis,  as  in  the  case  in  the  centre  of  an  ordinary  furuncle 
and  on  a  larger  scale  in  cases  of  progressive  phlegmonous  inflammation. 
The  fixed  tissue-cells  may  be  destroyed  by  starvation,  by  the  primary  inflam- 
matory exudation  being  so  abundant  as  to  obstruct  the  circulation  in  the 
inflamed  part.  If  the  cause  of  the  inflammation  is  less  intense,  as  is  the 
case  in  chronic  inflammation,  the  fixed  tissue-cells  are  brought  in  direct 
contact  with  the  microbes  which  produced  the  inflammation,  and  active 
tissue-proliferation  is  the  result,  and  this  furnishes  the  bulk  of  the  inflam- 
matory product.  The  histological  structure  of  tubercle  furnishes  a  good 
illustration  of  the  part  taken  by  the  fixed  tissue-cells  in  chronic  inflamma- 
tion. In  chronic  suppurative  inflammation  the  fixed  tissue-cells  are  first 
transformed  into  embryonal  tissue,  and,  as  the  protoplasm  of  the  new  cells 
is  destroyed  by  the  ptomaines  of  pus-microbes,  they  are  converted  into  pus- 
corpuscles.  A  passive  role  in  the  inflammatory  process  was  assigned  to  the 
fixed  tissue-cells  by  Boerhaave,  who  regarded  stasis  as  the  essential  feature 
of  inflammation;  by  Andral,  who  believed  that  hypersemia  was  the  charac- 
teristic pathological  condition  in  an  inflamed  part;  and  by  Eokitansky,  who 
taught  that  exudation  constituted  the  most  important  element  in  all  in- 
flammatory lesions.  Virchow  located  the  primary  seat  of  inflammation  in 
the  flxed  tissue-cells,  and  asserted  that  nutritive  or  formative  irritation  oc- 
curred in  them  independently  of  vessels  or  nerves.  He  maintained  that,  the 
more  the  cells  were  disposed  to  take  up  nutritive  material,  the  greater  the 
danger  that  they  themselves  would  be  destroyed.  Remaining  faithful  to 
the  doctrine  that  inflammation  is  only  caused  by  the  presence  and  action  of 
a  specific  microbic  cause,  we  shall  find  that,  the  more  acute  the  process,  the 
less  the  probability  that  the  fixed  tissue-cells  take  an  active  part,  and  that, 
the  more  chronic  the  inflammation,  the  greater  the  amount  of  the  new 
material  that  has  been  derived  from  the  fixed  tissue-cells,  and  the  smaller 
the  quantity  of  vascular  exudation. 

5.  Plasma-cells  and  Mast-cells. — An  occasional  cellular  product  of  in- 
flammation are  the  plasma-  and  mast-  cells.  Ivannoics  distinguishes  two 
distinct  morphological  forms  of  plasma-cells:  (1)  a  round  or  oval  cell,  which 
may  send  out  short  processes,  the  nucleus  being  deeply  stained  and  present- 
ing coarse  parietal  granules;  and  (2)  an  oval,  spindle-shaped  cell,  with 
numerous  processes  and  not  unlike  connective-tissue  cells;  the  nucleus  is 
long  and  the  chromatin  granules  more  lightly  stained  than  in  the  flrst. 
He  believes  the  first  are  derived  from  polymorphonuclear  leucocytes  and 
lymphocytes,  and  the  second  from  connective-tissue  cells,  and  claims  that 
this  cell  can  only  form  connective  tissue.  Gherardini  believes  that  the  mast- 
cells  are  identical  with  plasma-cells  and  that  they  originate  from  leucocytes 


100  PEINCIPLES    OF    SUEGEKY. 

and  which,  during  their  23hagocytic  activity,  retain  some  of  the  products  of 
cell-disintegration.  The  differences  between  the  mast-cell  and  plasma-cell 
are  simply  different  stages  in  the  development  of  the  same  cell. 

SYMPTOMS    or    INFLAMMATION. 

The  structural  changes  caused  by  inflammation  give  rise  to  a  charac- 
teristic complexus  of  symptoms, — pain,  redness,  swelling,  heat,  and  suspen- 
sion— diminution,  increase,  or  perversion  of  function.  These  symptoms  vary 
in  intensity,  according  to  the  nature  of  the  primary  cause  and  the  anatomical 
structure  and  location  of  the  tissues  affected.  One  or  more  of  the  symptoms 
enumerated  may  be  absent,  when  the  existence  of  inflammation  must  be 
ascertained  by  a  more  careful  study  of  those  presented.  In  acute  inflamma- 
tion the  symptoms  appear  in  rapid  succession  or  almost  simultaneously,  while 
in  the  chronic  form  they  come  on  slowly,  often  almost  insidiously,  and  fre- 
quently one  or  more  are  wanting,  even  when  the  disease  is  far  advanced. 
The  number  and  intensity  of  the  individual  symptoms  vary  not  only  accord- 
ing to  the  virulence  of  the  primary  microbic  cause,  but  are  also  modified 
by  the  resisting  capacity  of  the  individual  and  the  tissues  affected.  We  speak 
of  a  complete  or  partial  immunity  to  certain  microbic  diseases,  and  of  a  gen- 
eral or  local,  hereditary  or  acquired,  disposition.  For  diagnostic  purposes 
the  symptoms  must  be  studied  individually  and  collectively,  and  with  spe- 
cial reference  to  their  etiology  and  the  location  and  structure  of  the  inflamed 
tissues  or  organ. 

(a)  Pain. — Pain  is  one  of  the  most  variable  symptoms  of  inflammation. 
It  is  caused  by  traction  or  pressure  to  which  sensitive  nerve-filaments  are 
subjected  in  the  inflamed  tissues,  and  probably,  also,  in  some  instances,  at 
least,  by  extension  of  the  inflammatory  process  to  the  structure  of  the  nerves 
themselves.  Some  patients  are  more  sensitive  to  pain  than  others.  The 
same  extent  and  degree  of  inflammation  of  the  same  part  giving  rise  to  sen- 
sation of  discomfort  in  a  torpid  person  may  cause  excruciating  pain  in  pa- 
tients with  a  nervous  temperament.  As  the  degree  of  pain  will  depend 
largely  upon  the  number  of  sensitive  nerves  present  in  the  inflamed  area  and 
the  amount  of  exudation,  we  would  naturally  expect  to  find  pain  a  prominent 
symptom  in  inflammations  of  unyielding  tissue  freely  supplied  by  sensitive 
nerves.  This,  as  a  rule,  is  the  case.  Pain  is  a  distressing  symptom  in  cases 
of  phlegmonous  inflammation  of  the  fascia  and  tendon-sheaths  of  the  fingers 
and  palm  of  the  hand.  Pain  is  the  most  conspicuous  symptom  in  periostitis 
and  inflammation  of  the  serous  membranes.  Wherever  the  inflammatory 
exudation  appears  rapidly  in  parts  freely  supplied  with  sensitive  nerves,  pain 
from  tension  appears  as  one  of  the  foremost  symptoms,  and  continues  with- 
out intermission  until  tension  is  relieved.  In  acute  suppurative  osteomye- 
litis intense  pain  is  present  from  the  very  commencement  of  the  disease,  and 


SYMPTOMS    OF    INFLAMMATION.  101 

continues  unabated  until  tension  is  removed  by  operative  procedures,  or  by 
escape  of  inflammatory  product,  through,  some  defect  in  the  bone,  into  the 
more  yielding  paraperiosteal  tissues.  The  pain  is  throbbing,  sometimes  syn- 
chronously with  the  pulse,  in  acute  circumscribed  phlegmonous  inflamma- 
tion. It  is  sharp  and  lancinating  in  inflammation  of  serous  membranes.  It 
is  described  as  a  burning  sensation  in  inflammation  of  the  skin.  The  pain 
is  of  a  dull,  aching,  boring  character  in  deep-seated  inflammation,  especially 
in  the  interior  of  bone.  Nocturnal  exacerbation  of  pain  is  a  common  occur- 
rence, and  seldom  absent  in  painful  syphilitic  affections. '  The  pain  is  not 
always  referred  by  the  patient  to  the  seat  of  inflammation,  as  in  the  early 
stages  of  coxitis  it  is  not  in  the  hip,  but  over  the  inner  aspect  of  the  knee, 
and  in  inflammatory  affections  of  the  nerves  the  pain  radiates  along  the 
peripheral  branches,  and  is  usually  felt  most  severely  some  distance  from 
the  seat  of  the  disease,  at  points  supplied  by  the  peripheral  branches.  In 
ascertaining  the  existence  and  exact  location  of  a  deep-seated  inflammation, 
tenderness  is  a  more  valuable  symptom  than  spontaneous  pain.  Tenderness 
is  th-e  pain  elicited  by  pressure.  If  the  inflamed  part  is  tender  on  pressure 
and  accessible  to  palpation,  the  area  of  tenderness  will  correspond  to  the 
extent  of  the  inflammation.  During  the  beginning  of  an  attack  of  phleg- 
monous inflammation  the  surgeon  is  able  to  locate  the  affection  accurately 
by  searching  for  the  point  where  the  tenderness  is  most  acute,  and  the  same 
symptom  will  indicate  to  him,  earlier  than  any  other,  the  direction  in  which 
the  process  is  extending.  In  periostitis  the  area  of  tenderness  will  show 
whether  the  inflammation  is  circumscribed  or  diffuse.  The  existence  of  cir- 
cumscribed points  of  tenderness  about  the  epiphyses  of  the  long  bones  is 
almost  a  certain  indication  of  central  osseous  tuberculosis,  and,  at  the  same 
time,  furnishes  a  reliable  guide  in  their  early  operative  treatment.  Firm 
pressure  relieves  pain  in  nervous  hysterical  patients,  while  it  aggravates  it 
when  it  is  caused  by  inflammation.  On  the  other  hand,  superficial  pressure 
made  with  the  tips  of  the  fingers  increases  the  suffering  in  parts  the  seat  of 
functional  disturbance,  while  it  does  not  materially  affect  the  pain  resulting 
from  inflammatory  lesions. 

(b)  Redness. — The  composition  of  normal  blood  is  admirably  adapted 
for  the  passage  of  this  fluid  through  capillary  vessels.  As  long  as  the  relation 
of  corpuscular  elements  to  the  blood-plasma  remains  normal,  and  the  intima 
of  the  blood-vessels  remains  intact,  and  the  vis  a  tergo  is  adequate,  there  is 
no  tendency  to  capillary  obstruction.  If  the  capillary  circulation  in  the 
mesentery  of  a  frog  is  examined  under  a  microscope,  there  is  no  difficulty  in 
distinguishing  two  currents:  the  axial  and  peripheral.  The  axial,  or  central, 
current  is  rapid,  and  conveys  the  red  corpuscles,  which  have  the  same  spe- 
cific gravity  as  the  blood-plasma,  while  the  peripheral  current  between  the 
axial  and  vessel-wall  is  considerably  slower,  and  in  this  current  the  colorless 


103  PRINCIPLES    OF    SURGERY. 

corpuscles  are  conveyed,  their  rotating  motion  being  due  to  their  coming  in 
contact  with  the  wall  of  the  vessel.  D.  J.  Hamilton  has  shown,  by  numerous 
experiments,  that,  in  fluids  holding  in  suspension  solid  particles  passing 
through  capillary  tubes,  the  heaviest  particles  are  carried  along  the  central 
current,  while  those  specifically  lighter  than  the  fluid  seek  the  peripheral 
current.  The  leucocytes  are  specifically  lighter  than  the  fluid  in  which  they 
are  contained;  hence  they  are  forced  into  the  space  between  the  axial  cur- 
rent and  the  vessel-wall  (Fig.  63,  C).  The  third  corpuscle,  probably  for  the 
same  reasons,  moves  also  in  the  peripheral  stream.  The  colorless  corpuscles 
accumulate  more  in  the  peripheral  stream  when  the  current  is  feeble  than 
when  it  is  rapid.  This  fact  is  of  great  importance  in  the  study  of  the  altered 
circulation  when  the  capillary  vessels  are  in  a  state  of  inflammation.  The 
accumulation  of  colorless  corpuscles  in  the  peripheral  stream  in  inflamed 
capillary  vessels,  according  to  Thoma,  Eberth,  and  Schimmelbusch,  is  owed 
to  the  slowness  of  the  current,  which,  although  insufficient  to  propel  the 
specifically  light,  colorless  corpuscles,  is  still  competent  to  force  onward  the 
less-resisting  and  specifically  heavier-colored  corpuscles. 

Eberth  and  Schimmelbusch  state  that  in  the  vessels  of  a  warm-blooded 
animal  four  kinds  of  stream  are  noticed,  in  accordance  with  its  velocity:  (1) 
the  normal  stream,  in  which  the  axial  current  and  peripheral  zone  are  readily 
recognizable;  (3)  a  slow  stream,  in  which  the  leucocytes  accumulate  in  the 
periphery;  (3)  a  still  slower  stream,  in  which  the  third  corpuscles  also  leave 
the  axis  and  accumulate  in  the  periphery,  and  in  which,  these  observers  assert, 
the  leucocytes  become  less  numerous;  and  (4)  a  stream  so  slow  as  to  ap- 
proach stagnation,  in  which  all  the  elements  of  the  blood  are  indiscriminately 
mixed.  From  the  above  it  can  be  seen  that  all  general  and  local  conditions 
which  tend  to  diminish  the  velocity  of  the  blood-current  in  the  capillary 
vessels  are  productive  of  accumulation  of  the  colorless  corpuscles  and  of 
the  third  corpuscles  in  the  peripheral  stream:  a  condition  which  greatly  ag- 
gravates the  existing  local  impediments  to  capillary  circulation,  and  when 
well  advanced,  by  encroaching  more  and  more  upon  the  central  stream,  will 
result  in  complete  stasis.  Temporary  hypersemia  of  a  part  or  organ  is  a  fre- 
quent occurrence,  and  is  often  the  result  of  abnormal  innervation.  The  in- 
fluences of  the  nervous  system — particularly  of  the  sympathetic  nerves — 
over  the  circulation  are  familiar  to  every  student  of  physiology.  Temporary 
hypersemias  and  ansemias  of  certain  parts  or  organs  of  the  body — the  result 
of  abnormal  innervation  of  the  vasodilators  or  vasoconstrictors — frequently 
bring  about  vascular  changes  which  predispose  to  the  localization  of  the 
essential  microbic  cause  of  inflammation.  Injury  to  nerves,  mental  excite- 
ment or  depression,  and  exposure  to  cold  are  potent  factors  in  the  produc- 
tion of  temporary  vascular  disturbances.  Two  forms  of  active  hyperamia, 
due  to  faulty  innervation,  must  be  recognized.    When  caused  by  a  paralysis 


SYMPTOMS    OF    INFLAMMATION.  103 

of  the  vasoconstrictors  it  is  described  as  hypergemia  of  paralysis.  A  classical 
demonstration  of  this  form  of  hypersemia  was  furnished  by  Claude  Bernard 
by  his  experiment,  which  consisted  of  division  of  the  cervical  sympathetic 
in  the  rabbit,  which  was  invariably  followed  by  marked  hyperasmia  and  dila- 
tation of  the  blood-vessels  in  the  ear  on  the  corresponding  side.  When  the 
vasodilators  are  irritated  by  mechanical  or  electrical  stimulation  the  arte- 
rioles dilate  and  the  part  presided  over  by  the  affected  nerve  becomes  hyper- 
semic,  and  the  condition  of  the  circulation  is  known  as  hypersemia  of  irrita- 
tion, A  good  illustration  of  this  form  of  hyperasmia  can  be  produced  by 
stimulation  of  the  chorda-tympani  nerve,  which,  as  was  shown  first  by 
Claude  Bernard,  always  produces  dilatation  of  the  vessels  in  the  submaxillary 
gland.  Passive  hyperemia  is  caused  by  mechanical  conditions  which  inter- 
fere with  the  return  of  venous  blood.  Ligation  of  a  vein  furnishes  the  sim- 
plest variety  of  this  form  of  venous  congestion.  Thrombophlebitis;  varicose 
veins;  pressure  upon  veins  caused  by  tumors,  the  pregnant  uterus,  and  in- 
flammatory products;  and  pressure  caused  by  a  dislocation  or  fractured 
bone,  as  well  as  organic  disease  of  the  heart  and  lungs  and  cirrhosis  of  the 
liver,  afford  familiar  instances  of  the  more  common  mechanical  interfer- 
ences with  the  venous  circulation.  The  chronic  or  frequently-recurring  hy- 
peremia in  a  part  usually  results  in  increased  nutritive  activity  of  the  tissues 
and  hyperplasia  in  the  absence  of  infection.  This  effect  of  chronic  hyper- 
semia has  been  made  use  of  in  practice  by  producing  the  condition  artificially 
in  the  treatment  of  tubercular  affections  accessible  to  this  kind  of  treatment 
(Bier).  Eedness  as  a  symptom  of  inflammation  signifies  an  excess  of  blood 
in  the  part,  and  the  terms  used  to  indicate  its  existence  are  hypersemia  and 
congestion,  while  complete  arrest  of  the  capillary  circulation  is  expressed  by 
the  word  stasis.  Accurately  speaking,  hyperemia  should  be  used  to  designate 
that  condition  of  the  circulation  where  the  part  not  only  contains  an  in- 
creased amount  of  blood,  but  where  an  increased  amount  of  blood  flows  to 
and  returns  from  the  part:  an  exalted  physiological  process;  while  the  word 
congestion  literally  means  only  an  accumulation  of  blood  in  a  part:  a  con- 
dition owed  to  some  form  of  local  or  distant  mechanical  obstruction.  The 
conditions  giving  rise  to  redness,  hypersemia,  congestion,  and  stasis  should 
not  be  studied  only  from  descriptions,  but  in  order  to  be  understood  they 
should  be  seen.  This  can  be  readily  done  by  producing  artificially  an  in- 
flammation in  a  transparent  part  of  some  lower  animal,  preferably  the  frog, 
and  studying  the  circulation  in  the  inflamed  part  step  by  step  under  the  mi- 
croscope. For  this  purpose  experimenters  have  usually  selected  the  frog's  web, 
mesentery,  tongue,  lung,  and  bladder,  and  the  tadpole's  tail.  For  general  use 
the  frog's  web  should  be  selected,  as  the  preparations  for  this  experiment  are 
very  simple.  Inflammation  is  provoked  by  cauterizing  the  web  with  a  needle 
heat-ed  to  a  red  heat,  or  by  applying  with  a  small  plug  of  cotton  some  power- 


104 


PRINCIPLES    OF    SUEGEEY. 


ful  irritant,  as  ammonia,  tincture  of  cantharides,  or  croton-oil,  or  by  touch- 
ing the  surface  with  a  sharp  stick  of  nitrate  of  silver.  Hamilton  gives  the 
following  directions  for  making  the  experiment:  "Nothing  more  is  neces- 
sary than  a  piece  of  tin  or  other  soft  metal,  about  1  ^/g  to  2  inches  broad  and 
about  6  to  8  inches  long,  or,  what  is  better,  a  thin  piece  of  hard  wood  of  the 
same  dimensions.  At  the  end  where  the  web  is  to  be  stretched  it  should  not 
be  so  broad.  From  the  narrow  end  of  this  a  V-shaped  piece  is  cut  out,  over 
which  the  web  is  to  be  spread.  The  frog  should  first  be  curarized,  as  this 
does  not  interfere  with  the  circulation,  provided  that  the  solution  employed 


Fig.  63. — Normal  Circulation  in  Frog's  Web.  A,  artery;  B,  vein;  O,  capillaries. 
Vessels  covered  by  a  net-work  of  polygonal  epithelial  cells  of  web,  in  which  pigmented 
cells  are  not  represented.     (Landerer.) 

be  not  too  strong.  The  ^/aooo  of  a  grain,  in  watery  solution,  injected  under 
the  skin,  is  sufficient.  Chloral  may  be  substituted.  Caton  recommends  a 
solution  of  4  grains  to  the  drachm.  As  many  minims  should  be  injected 
subcutaneously  as  the  frog  is  drachms  in  weight.  The  injection  is  made  un- 
der the  skin  of  the  back  with  an  ordinary  hypodermic  syringe.  The  animal 
is  laid  on  the  piece  of  metal  or  wood,  and,  the  web  being  stretched  over  the 
cleft  at  the  end,  the  toes  are  held  by  tying  a  piece  of  thin  thread  to  them 
and  fixing  the  ends  into  a  fine  slit  cut  in  the  metal  or  wood."  The  micro- 
scope is  so  arranged  and  adjusted  that  the  field  of  observation  will  correspond 
to  the  point  of  irritation.    A  sufficiently  high  power  is  used  so  that  the  dif- 


SYMPTOMS    OF    INFLAMMATION. 


105 


ferent  corpuscular  elements  in  the  capillary  stream  can  be  readily  seen  and 
recognized.  In  order  to  witness  the  different  stages  of  the  inflammatory 
process  it  is  necessary  to  continue  the  observation  for  hours. 

Any  one  of  the  irritants  mentioned  applied  to  the  frog's  web  will  pro- 
duce in  the  capillaries  over  a  limited  area  a  series  of  changes  which  are  always 
present  in  inflammation,  and  a  description  of  them  will  represent  what  takes 
place  in  capillaries  the  seat  of  inflammatory  processes  of  bacterial  origin; 
almost  simultaneously  with  the  application  of  the  irritant  a  momentary  con- 
traction of  the  vessel  occurs,  caused  by  the  stimulation  of  the  vasocon- 
strictor nerves,  which  is  followed  b}^  dilatation,  with  increased  velocity  of 


Fig.  64.— Capillaries  of  Frog  s  Web  m  a  State  of  Hyperasmia  soon  after  Application  of 
Irritant.    A,  artery;    B,  vein;    C,  capillaries.     (Landerer.) 

the  capillary  current:  a  true  hypergemia.  The  bright-red  color  of  the  hyper- 
ffimic  part  at  this  stage,  according  to  Eecklinghausen,  is  due  to  increase  in 
the  rapidity  of  the  blood-current,  but,  as  the  color  of  the  blood  indicates  a 
diminished  expenditure  of  oxygen  and  a  smaller  quantity  of  carbon  in  the 
blood,  increased  velocity  alone  would  not  explain  this  change.  Diminished 
alkalescence  in  the  inflamed  tissues  may  reduce  the  amount  of  oxygen  used, 
as  is  the  case  in  glands  during  active  secretion,  where  Claude  Bernard  showed 
that  defective  oxygenation  is  always  present.  At  this  stage  the  corpuscular 
elements  circulate  in  their  respective  streams,  and  the  whole  picture  is  one 
of  increased  physiological  activity.     Dilatation  of  the  vessels  follows  con- 


106 


PRINCIPLES    OF    SURGEET. 


traction  so  quickly  that  it  would  be  difficult  to  explain  it  as  a  paralytic  phe- 
nomenon. Its  early  outset  and  the  rapidity  with  which  it  appears  would 
point  to  a  neurotic  cause,  traceable  to  the  action  of  ganglia  in  the  vessel- 
wall.  It  has  not  yet  been  satisfactorily  explained  whether  this  early  dilata- 
tion of  the  vessel  is  due  to  vasomotor  paralysis  or  irritation  of  the  vaso- 
dilators, but  it  is  more  probable  that  it  is  caused  by  the  vasodilators, 
while,  later,  paralysis  from  overdistension  occurs.  Division  of  the  sym- 
pathetic in  the  neck  brings  about  increased  vascularity,  but  no  inflam- 
mation. The  difference  between  dilatation  of  an  inflamed  vessel  and  the 
dilatation  following  division  of  the  sympathetic  consists  in  alteration  of  the 
capillary  wall,  in  the  former  instance  produced  by  the  action  of  the  causes 


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Fig.  65. — Plasma-cells  in  Acute  Interstitial  Nephritis.     (Low  power.) 


which  induced  the  inflammation,  while  in  the  latter  the  dilatation  is  a 
purely-nervous  phenomenon,  unattended  by  other  pathological  conditions 
of  the  vessel-wall.  Disturbances  of  the  circulation  alone  are  not  sufficient 
to  bring  about  the  local  changes  which  are  characteristic  of  inflammation; 
if  the  velocity  of  the  blood-current  is  greatly  diminished  by  purely  mechan- 
ical or  nervous  causes,  mural  implantation  of  the  white  corpuscles  may  take 
place,  but  emigration  does  not  occur  on  account  of  the  absence  of  the  essen- 
tial condition  which  gives  rise  to  it:   alteration  of  the  capillary  wall. 

Dilatation  is  first  noticed  in  the  smallest  arteries,  afterward  in  the  veins 
and  capillaries,  and  keeps  increasing  from  fifteen  minutes  to  two  hours. 
The  vessels  often  enlarge  to  double  their  normal  calibre.  During  the  stage 
of  dilatation  many  of  the  capillaries  which  were  small  or  contained  but  little 


SYMPTOMS    OF    INFLAMMATION.  107 

blood  become  visible,  which  greatly  adds  to  the  tiirgidity  and  redness  of  the 
inflamed  part.  As  long  as  the  acceleration  of  the  capillary  current  con- 
tinues, the  different  corpuscles  move  in  their  respective  currents.  The  white 
corpuscles  that  are  mingled  with  the  colored  are  washed  along  with  the  latter 
in  the  central  stream  without  finding  their  way  into  the  slower  side-current 
which  propels  the  leucocytes  and  the  third  corpuscles.  The  leucocytes  in 
the  peripheral  stream  appear  more  numerous,  and  skip  along  by  more  rapid 
rotatory  movements.  At  this  time  the  circulation  has  reached  its  greatest 
speed,  and  the  tissues  present  every  appearance  of  well-marked  hypersemia. 
In  from  fifteen  minutes  to  two  hours  from  the  time  the  irritant  was  applied 
intravascular  changes  are  noticed  which  are  calculated  to  impede  the  capil- 
lary current.  The  first  link  in  the  chain  of  local  causes  which  obstruct  the 
capillary  circulation  consists  of  a  crowded  condition  of  the  vessels  from  a 
greater  accumulation  of  the  different  corpuscles,  which  is  soon  followed  by 
a  greater  separation  of  the  leucocytes  from  the  central  cun-ent  and  their 
greater  accumulation  in  the  peripheral  stream,  where  they  often  become 
arranged  in  heaps  and  little  masses.  This  change  is  first  observed  in  the 
small  veins,  and  somewhat  later,  and  to  a  lesser  extent,  in  the  smallest 
arteries.  Separation  of  the  blood-corpuscles  is  the  necessary  outcome  of 
slowing  of  the  stream  from  greater  accumulation.  In  the  peripheral  zone 
of  leucocytes  the  next  source  of  obstruction  is  created.  Some  of  the  colorless 
corpu.scles  become  momentarily  attached' to  the  capillary  wall,  when  they 
are  again  detached  by  the  force  of  the  current,  or  are  rolled  away  by  another 
leucocyte.  As  the  process  advances  it  appears  as  though  the  viscosity  of  the 
leucocytes  was  increasing  constantlj^,  as  more  and  more  of  them  become  ad- 
herent, while  fewer  are  again  detached.  The  lumen  of  the  vessel  is  narrowed 
more  and  more  by  mural  implantation  of  the  leucocytes.  The  small  veins 
now  assume  an  appearance  as  if  the  internal  surface  of  their  wall  were  paved 
with  leucocytes,  while  in  the  capillaries  a  similar  adhesion  of  the  leucocytes 
to  the  wall  is  noticed.  At  this  stage  it  often  appears  as  though  complete  ob- 
struction would  occur  every  moment,  the  capillary  stream  becoming  com- 
pletely arrested  for  a  moment,  and  the  current  may  even  move  in  an  opposite 
direction,  when  the  obstruction  is  again  overcome  and  the  current  moves  once 
more  in  the  right  direction.  The  smallest  arteries  exert  themselves  to  the 
utmost  to  clear  the  way,  and  pulsations  can  be  seen  where,  in  a  normal  con- 
dition, they  are  absent.  Hypergemia  has  now  given  way  to  congestion.  An 
intravascular  obstruction  has  given  rise  to  accumulation  of  blood  on  the  prox- 
imal side  of  the  inflamed  vessel.  Increasing  slowing  of  the  current  gives  rise 
to  greater  accumulation  of  leucocytes,  which  become  firmly  adherent  to  the 
capillary  wall,  narrowing  the  vessel  more  and  more  until  the  space  for 
the  axial  current  becomes  too  small  for  the  passage  of  the  red  corpuscles, 
when  complete  arrest  of  the  circulation  takes  place.    Congestion  has  resulted 


108  PEINCIPLES    OF    SUEGEEY. 

in  stasis.  As  soon  as  complete  stasis  has  taken  place  the  colorless  corpuscles 
become  mixed  with  the  red  corpuscles  which  are  forced  into  the  mass  of  the 
white,  while  by  amoeboid  movements  the  latter  wander  toward  the  centre  of 
the  vessel  and  mix  freely  with  those  which  were  moving  in  the  central  cur- 
rent. The  most  advanced  stages  of  vascular  disturbance  are,  of  course, 
noticed  first  where  the  irritant  was  applied;  so  that  when  complete  stasis  has 
taken  place  in  the  centre  a  zone  of  congestion  surrounds  this,  while  more 
distant  vessels  still  present  every  indication  of  active  hypersemia.  Eedness 
is  most  marked  where  hyperemia  is  extant;  that  is,  in  parts  containing  a 
maximum  amount  of  arterial  blood.  As  soon  as  congestion  sets  in,  the  blood- 
corpuscles,  red  and  white,  do  no  longer  pass  through  the  vessel  with  the  same 
rapidity  and  number,  and  the  redness  gives  way  to  a  bluish  tinge,  which  be- 
comes well  marked  and  does  not  give  way  to  pressure  when  complete  stasis 


rn^^i^^^.    -(&?' 


[Q  ^^  @®         ^^ 


Fig.  66. — Three  Plasma-cells  in  Acute  Interstitial  Nephritis.     (High  power.) 

has  occurred.  The  blood  in  the  stagnated  vessels,  according  to  Paget,  has 
little  tendency  to  coagulate;  hence  the  possibility  of  restitutio  ad  integrum 
of  the  circulation  after  subsidence  of  the  acute  symptoms.  Complete  stasis 
occurs  first  in  such  capillaries  where  the  vis  a  tergo  is  greatly  diminished  by 
a  circuitous  route  from  an  artery  to  a  vein,  and  increases  in  the  direction 
in  which  the  blood-current  is  slowest.  In  warm-blooded  animals  the  phe- 
nomena of  inflammation  do  not  differ  materially  from  those  observed  in  the 
frog's  web,  except  as  regards  the  presence  and  disposition  of  the  third  cor- 
puscles. According  to  Eberth  and  Schimmelbusch,  in  warm-blooded  ani- 
mals the  third  corpuscles  in  the  normal  capillary  circulation  move  along 
with  the  colored  corpuscles  in  the  axial  current,  and  hence  they  maintain 
that  they  must  be  of  nearly  the  same  specific  gravity.  A  few  of  the  leuco- 
cytes, mixed  with  the  colored  corpuscles  and  the  third  corpuscles,  are  found 


SYMPTOMS    OF    INFLAMMATION.  ]  09 

in  the  central  stream,  but  the  majority  of  them  are  propelled  by  the  periph- 
eral stream,  which,  according  to  those  observers,  is  from  ten  to  twenty  times 
slower  than  the  central  or  axial  current.  With  the  slowing  of  the  stream 
from  alteration  of  the  capillary  wall  and  subsequent  intravascular  conditions, 
separation  of  the  corpuscles  takes  place  in  the  same  manner  as  has  been  de- 
scribed in  the  frog's  web;  the  leucocytes  and  third  corpuscles  leave  the 
central  stream  and  accumulate  in  the  slower  peripheral  zone  of  the  capillary 
stream,  where  they  give  rise  to  a  greater  degree  of  slowing  of  the  column 
of  blood  by  the  formation  of  intravascular  obstruction,  which,  if  sufficient 
in  degree,  finally  arrests  the  central  current,  thus  causing  stasis.  The  in- 
flammatory process  in  warm-blooded  animals  can  be  studied  advantageously 
in  the  artifically-inflamed  omentum  of  young  animals,  especially  the  guinea- 
pig,  as  the  omentum  in  these  animals  is  exceedingly  delicate  and  transparent. 
The  animal  is  narcatized  by  injecting  subcutaneously  3  grains  of  hydrate 
of  chloral  for  a  full-grown  animal.  As  the  animal,  with  the  exception  of 
the  head,  is  to  be  kept  immersed  in  a  physiological  solution  of  salt  kept  at  a 
temperature  of  the  body  in  a  large  vat  with  a  glass  bottom,  it  is  wrapped 
in  a  sheet  of  gutta-percha  tissue  long  enough  to  overlap  the  head,  and 
made  so  as  to  inclose  a  funnel-like  space  through  which  it  may  breathe.  An 
opening  is  made  in  the  covering  at  a  point  corresponding  to  the  abdominal 
incision,  through  which  the  omentum  is  withdrawn.  The  object-glass  of 
the  microscope  is  immersed  in  the  solution,  and  the  omentum  laid  over  a 
slide  without  fastening  it.  The  vat  is  made  so  that  it  will  fit  on  to  the  stand 
of  an  ordinary  microscope,  so  that  the  light  can  be  readily  adjusted.  Two 
tubes,  one  to  convey  the  salt  solution  into  the  vat  and  another  to  conduct  it 
away,  are  attached  at  opposite  sides.  These  can  be  connected  with  a  vessel 
the  temperature  of  which  is  kept  constant  by  means  of  a  thermostat  and  Bun- 
sen  burner. 

(c)  Swelling. — The  primary  swelling  in  inflammation  is  due  to  dila- 
tation of  blood-vessels,  and  its  degree  will  depend  on  the  vascularity  of  the 
part  inflamed.  The  more  numerous  the  blood-vessels,  the  greater  the  swell- 
ing from  this  cause.  As  the  inflamed  blood-vessels  will  often  dilate  within 
two  hours  to  double  their  normal  calibre,  the  primary  swelling  in  vascular 
organs  in  a  state  of  acute  inflammation  will  come  on  quickly,  and  will  give 
rise  to  a  not  inconsiderable  enlargement  of  the  inflamed  part.  If  during  this 
stage  of  inflammation  the  tissues  are  incised,  hemorrhage  is  profuse,  and 
the  emptying  of  turgid  blood-vessels  by  this  means  has  a  prompt  effect  in 
diminishing  the  swelling.  Nancrede  has  shown  by  his  investigations  that 
local  depletion,  during  the  hyper£emic  stage  of  inflammation,  exercises  a 
favorable  influence  in  unloading  the  distended  blood-vessels  and  in  modi- 
fying the  intensity  of  the  subsequent  conditions  in  the  inflamed  tissues.  It 
is  also  during  this  stage  that  the  application  of  cold  proves  a  beneficial  re- 


110  PEINCIPLES    OF    SURGERY. 

source  in  the  treatment  of  acnte  inflammation^  as  under  its  effects  the  dis- 
tended blood-vessels  contract,  and  in  consequence  of  the  diminution  of  the 
vascularity  of  the  inflamed  part  the  primary  inflammatory  swelling  is  dimin- 
ished. 

1.  Inflammatory  Exudation. — A  moderate  amount  of  swelling  is  pres- 
ent in  all  regenerative  processes,  as  dilatation  of  the  vessels  necessarily  pre- 
cedes the  increased  physiological  activity  of  the  tissue,  and  the  embryonal 
material  required  in  the  reparative  process  occupies  a  larger  volume  than  the 
mature  tissue  it  is  intended  to  replace.  Inflammation  is  characterized  by  the 
presence  of  a  superabundance  of  cells.  The  cause  which  has  produced  the 
inflammation  has,  by  its  direct  action  upon  the  capillary  wall,  produced  such 
alterations  of  its  structure  as  to  render  it  more  porous,  hence  permeable  to 
the  passage  of  the  inclosed  cellular  elements  of  the  blood.  The  albuminous 
cement-substance  which  holds  together  the  endothelial  cells  disintegrates  at 
different  points,  and  through  these  small  defects,  the  stigmata  and  stomata, 
the  blood-corpuscles  find  their  way  through  the  capillary  wall  into  the  sur- 
rounding lymph-  and  connective-tissue  spaces.  In  acute  inflammation  the 
inflammatory  exudation  consists  principally  in  the  extravascular  accumula- 
tion of  blood-corpuscles  which  have  passed  through  the  injured  capillary 
wall.  The  rapidit}^  with  which  the  inflammatory  exudation  appears  will 
depend  on  the  intensity  of  alteration  of  the  capillary  wall  and  the  speed 
with  which  the  blood-corpuscles  escape  into  the  surrounding  tissues.  In 
chronic  inflammation  exudation  takes  place  slowty,  and  the  histological  ele- 
ments of  the  inflammatory  swelling  are  derived  mostly  from  the  fixed  tissue- 
cells.  Eecently  it  has  been  asserted  that  the  inflammatory  exudate  of  mu- 
cous and  serous  surfaces,  or  what  has  been  considered  as  such,  is  not  the 
product  of  cell-emigration  or  cell-production,  but  consists  of  a  form  of  de- 
generation of  the  affected  tissues.  Neumann  believes  that  it  represents  a 
fibrinoid  degeneration  of  the  superficial  connective  tissue  resembling,  in  this 
respect,  amyloid  degeneration.  In  favor  of  this  view  is  the  localization  of 
patches,  which  would  not  occur  if  there  was  a  fluid  exudate,  as  the  rubbing 
of  the  pleurae  or  the  peristaltic  action  of  the  intestines  would  tend  to  spread 
it,  in  inflammation  of  these  organs.  He  was  able  to  demonstrate  endothe- 
lium covering  the  patches.  Georgiewsky  studied  fibrinous  exudates  by  means 
of  injection  of  solutions  of  iodine.  During  the  first  twenty-four  hours  after 
injection,  especially,  appearances  are  presented  that  might  be  mistaken  for 
a  fibrinous  degeneration  of  the  connective  tissue,  such  as  Neumann  claims 
takes  place  in  fibrous  inflammation  of  serous  membranes.  The  connective- 
tissue  fibres  swell  up  and  are  loosened,  the  lymph-spaces  are  widened,  and 
leucocytic  infiltration  takes  place;  but,  although  the  fibres  now  take  the 
fibrin-stain,  the  vessels  always  remain  distinct  and  do  not  form  part  of  the 
exudate.     A  certain  amount  of  tissue-degeneration  and  necrosis  certainly 


SYMPTOMS    OF    INFLAMMATION.  Ill 

takes  place  in  acute  inflammation,  but  the  established  views  that  the  inflam- 
matory exudate  consists  largely  of  fibrin  and  the  product  of  cell-migration 
has  not  been  undermined  by  Neumann's  experiments. 

Emigration  of  Leucocytes. — The  passage  oi  a  leucocyte  through  a  defect 
in  the  capillary  wall  is  called  emigration;  the  wandering  of  such  a  cell  from 
a  place  where  it  has  a  normal  existence  into  a  territory  where  in  a  condition 
of  health  it  does  not  exist  is  seldom  met  with.  After  it  has  made  its  escape 
from  the  capillary  vessel  it  is  called  an  emigration,  or  wandering,  corpuscle. 
John  Hunter  came  very  near  being  the  discoverer  of  emigration  of  leuco- 
cytes during  his  researches  on  inflammation.  He  incised  the  tunica  vaginalis 
in  animals,  and  inserted  a  tallow  plug,  which  he  removed  after  short  inter- 
vals, and  examined  the  fluid  upon  its  surface  under  the  microscope.  He 
found  in  this  fluid,  a  short  time  after  the  incision  was  made,  round,  white 
cells,  which  could  have  been  nothing  else  but  wandering  leucocytes. 

The  credit  for  having  demonstrated  the  porosity  of  the  capillary  wall 
and  the  escape  of  the  colorless  corpuscles  unquestionably  belongs  to  Waller. 
This  author  observed  emigration  in  the  tongue  of  .the  frog  as  early  as  1846, 
and  strongly  maintained  that  the  inflammatory  exudates  were  composed 
largely  of  leucocytes,  in  opposition  to  the  blastema  theory  of  formation  of 
pus  and  other  inflammatory  products. 

In  1849  Addison  clearly  pointed  out  the  relationship  of  the  colorless 
corpuscles  and  the  corpuscles  lying  around  the  vessels  in  inflamed  parts,  as 
becomes  evident  from  the  following  sentences  from  his  work  on  "Consump- 
tion and  Scrofula":  "During  inflammation — using  the  word  in  the  general 
sense  here  indicated — there  'is  more  or  less  marked  increase  of  the  colorless 
elements  and  protoplasm  in  the  part  affected.  At  first — in  the  first  stage — 
these  elements  adhere  but  slightly  along  the  inner  margin  or  boundary  of 
the  nutrient  vessels,  and  are  therefore  still  within  the  influence  of  the  cir- 
culating current,  belonging,  as  it  were,  at  this  period  as  much,  or  rather 
more,  to  the  blood  than  to  the  fixed  solid.  Secondly — in  the  second  stage— 
they  are  more  firmly  fixed  in  the  walls  of  the  vessels,  and,  therefore,  now 
without  the  influence  of  the  circulating  current.  Thirdly — in  the  third 
stage — new  elements  appear  at  the  outer  border  of  the  vessels,  where  they 
add  to  the  texture,  form  a  new  product,  or  are  liberated  as  an  excretion." 

Eecklinghausen  found  wandering  corpuscles  in  the  vascular  spaces  of 
the  cornea,  but  he  believed  that  they  were  a  product  of  tissue-proliferation 
from  the  flxed  corneal  corpuscles.  Our  modern  knowledge  of  emigration  of 
leucocytes  is  founded  almost  exclusively  upon  the  labors  of  Cohnheim.  This 
observer  demonstrated,  in  the  year  1867,  by  his  own  ingenious  experiments, 
that  the  wandering  corpuscles  discovered  by  Eecklinghausen  in  the  vascular 
spaces  of  the  cornea  were  leucocytes  which  had  escaped  from  capillary  vessels 
and  had  wandered  into  the  cornea.    He  based  his  statements  on  the  results 


113  PEINOIPLES    OF    SUEGEKY. 

of  an  experiment  which  could  leave  no  room  for  discussion.  He  injected 
finely-divided  pigment-material  directly  into  the  circulation  of  an  animal, 
and  somewhat  later  produced  artificially  a  keratitis.  In  examining  the 
cornea  he  found  the  vascular  spaces  nearest  the  margin  of  the  cornea  crowded 
with  leucocytes  loaded  with  pigment-granules.  There  could  be  only  one 
conclusion, — that  the  leucocytes,  which  had  become  charged  with  pigment- 
granules  in  the  general  circulation,  had  passed  through  the  capillary  vessels 
at  a  point  nearest  the  seat  of  irritation;  in  other  words,  the  capillary  vessels 
which  took  part  in  the  traumatic  keratitis  furnished  the  primary  inflamma- 
tory exudation.  A  slight  irritation  of  a  frog's  web  will  only  produce  an 
active  hyperseniia,  and  in  a  short  time  the  circulation  returns  to  normal  with- 
out any  emigration  of  leucocytes  having  taken  place.  In  such  cases  the  irri- 
tant has  been  of  such  a  nature  or  of  such  mild  action  as  not  to  produce  the 
necessary  alteration  of  the  capillary  wall  for  mural  implantation  and  emigra- 
tion to  take  place. 

Zahn  has  shown  that  if  the  mesentery  of  an  animal  is  exposed,  but  care- 
fully protected  against  injury,  emigration  of  leucocytes  does  not  take  place 
for  seven  or  eight  hours,  while  the  remaining  disturbances  of  the  circulation 
indicate  the  existence  of  inflammation.  If,  however,  the  frog^s  web  or  tongue 
is  cauterized  with  a  sharp-pointed  pencil  of  nitrate  of  silver  the  necessary 
conditions  for  an  acute  inflammation  are  created,  and  the  minute  eschar 
is  soon  surrounded  by  vessels  showing  the  difi:erent  stages  of  the  inflamma- 
tory process,  from  active  hypergemia  to  complete  stasis.  Emigration  of  leu- 
cocytes takes  place  most  actively  in  capillaries  partly  obstructed  by  mural 
aggregation  of  these  elements,  and  the  process  is  arrested  as  soon  as  the  cir- 
culation has  come  to  a  complete  stand-still.  The  following  conditions  must 
be  present  and  are  essential  for  emigration  of  leucocytes:  1.  Alteration  of 
capillary  wall.  2.  Mural  implantation  of  leucocytes.  3.  Permeability  of 
lumen  of  capillary  vessel.    4.  Amcsboid  movements  of  leucocytes. 

1.  Alteration  of  the  capillary  wall  has  been  repeatedly  enumerated  as 
the  most  important  feature  of  inflammation,  and  without  such  a  change  the 
rapid  escape  of  leucocytes  as  we  find  it  in  inflammation  would  be  utterly  im- 
possible. The  cause  which  has  produced  the  inflammation  produces  such 
a  degree  of  softening  in  the  cement-substance  as  to  enable  its  penetration  by 
the  leucocytes  between  the  endothelial  cells,  or,  as  some  of  the  authors 
claim,  localized  minute  defects  cause  the  formation  of  small  openings 
through  which  the  leucocytes  escape. 

2.  Mural  implantation  of  leucocytes  is  an  equally  essential  condition, 
as  without  it  the  leucocytes,  which  are  at  any  rate  larger  in  circumference 
than  the  supposed  openings  through  which  they  escape,  would  be  rolled  over 
these  minute  defects  by  the  sluggish  peripheral  stream,  and  emigration 
would  not  take  place.    Increased  adhesiveness  or  viscosity  of  the  leucocytes 


SYMPTOMS    OP   INFLAMMATION. 


113 


is  supposed  to  play  an  important  part  in  the  occurrence  of  mural  implanta- 
tion. According  to  Hering,  mural  fixation  of  the  leucocytes  is  effected  by 
fine  projections,  which  are  thrown  out  on  their  surface,  and  which  insinuate 
themselves  into  the  small  crevices  of  the  roughened  intima.  Mural  implanta- 
tion cannot  take  place  as  long  as  the  capillary  stream  retains  its  normal 
velocity;  hence,  slowing  of  the  peripheral  current  is  the  first  and  most  im- 
portant cause.  The  slower  the  peripheral  stream,  the  more  readily  does 
mural  implantation  occur,  and  the  greater  the  tendency  to  aggregation  of 
leucocytes  along  and  near  the  capillary  wall.  The  rapid  transudation  of  the 
plasma  of  the  blood  through  the  defective  capillary  is  undoubtedly  another 
cause  of  impediment  of  progress  and  final  adhesion  of  leucocytes  to  the  inner 


ri*' 


Fig.  67.— Leucocyte  Passing  through  Capillary  Wall.    A,  leucocyte  attached  to  capil- 
lary wail  by  delicate  processes;    higher  up  it  has  penetrated  the  capillary  wall  by  a  large 
projection.    B,  half  of  the  leucocyte  outside  of  the  capillary  wall  dragging  the  remainder     . 
after  it.     (Landerer.) 

surface  of  the  capillary  vessel.  Finally,  mural  fixation  of  leucocytes  is  ef- 
fected by  the  changed  condition  of  the  protoplasm  of  the  leucocytes  and  the 
inner  surface  of  the  capillary  wall  by  the  action  of  the  essential  cause  which 
produced  the  inflammation. 

3.  It  has  been  shown  that  emigration  of  leucocytes  is  most  active  where 
the  capillary  circulation  has  become  impeded,  but  not  arrested,  and  that  the 
process  is  arrested  with  the  occurrence  of  complete  stasis;  hence,  it  appears 
that  the  intravascular  pressure  is  one  of  the  factors  in  this  process.  Hering 
and  Sehklarewsky  maintained  that  the  leucocytes  are  entirely  passive  struct- 
ures in  their  passage  through  the  capillary  wall,  that  they  are  forced  through 
defects  in  the  wall  exclusively  by  the  intravascular  pressure.     That  emigra- 


114  PEINCIPLES    OF    SURGERY. 

tion  is  not  such  a  simple  process  is  evident,  as  there  would  be  in  such  case 
a  larger  representation  of  colored  corpuscles  in  the  inflammatory  exudation. 
The  blood-pressure  assists  in  the  extrusion  of  leucocytes  that  have  penetrated 
the  capillary  wall,  but,  without  changes  in  their  form,  would  not  be  ade- 
quate to  force  them  through  the  minute  openings  or  the  softened  cement- 
substance. 

4.  Leucocytes,  in  order  to  pass  through  an  inflamed  capillary  wall,  must 
possess  amoeboid  movements;  hence,  only  living  leucocytes  are  capable  of 
migration. 

After  the  leucocyte  has  become  implanted  upon  the  inner  surface  of 
the  capillary  wall  it  penetrates  the  softened  cement-substance  by  throwing 
out  projections,  or  one  of  these  projections  insinuates  itself  into  one  of  the 
minute  foramina,  and  as  the  extramural  portion  increases  in  size  the  re- 
mainder of  the  leucocyte  is  drawn  toward  it;  this  step  is  greatly  aided  by 
the  blood-pressure,  which  pushes  the  intravascular  portion  in  the  direction 
of  the  growing  projection,  until  by  its  own  exertions,  and  aided  by  the  vis 
a  tergo,  it  has  finished  its  journey  through  the  capillary  wall,  and  has  reached 
the  paravascular  lymph  or  connective-tissue  spaces,  where  it  constitutes  the 
most  important  element  of  the  inflammatory  exudation.  In  the  inflamed 
capillaries  of  the  frog's  web,  under  the  microscope,  this  process  of  emigra- 
tion can  be  readily  followed,  and  leucocytes  can  be  seen  in  the  same  field  in 
various  stages  of  transit  through  the  wall,  and  finally  liberated  in  the  para- 
vascular spaces.  Frequently  one  leucocyte  after  another  can  be  seen  pass- 
ing through  the  same  place:  a  fact  which  points  strongly  to  the  existence 
of  well-defined  circumscribed  defects  in  the  capillary  wall.  As  the  escaped 
leucocytes  accumulate  outside  of  the  capillary  vessels,  some  of  them  can  be 
seen  to  change  their  location  by  the  same  forces  which  have  been  active  in 
their  passage  through  the  vessel- wall:  amoeboid  movements  and  stream  of 
parenchyma-fluid. 

Diapedesis.— This  word  was  devised  by  Strieker  to  designate  the  passage 
of  colored  corpuscles  through  the  inflamed  vessel-wall.  If  there  could  be 
any  doubt  as  to  the  existence  of  minute  openings  in  the  inflamed  capillary 
wall  in  the  consideration  of  emigration  of  leucocytes,  this  doubt  must  be 
effectually  dispelled  when  the  passage  of  colored  corpuscles  through  the 
capillary  wall  can  be  demonstrated  under  the  microscope.  Experimental 
research  and  clinical  observation  have  shown  that  when  the  inflammatory 
action  is  very  intense  red  corpuscles  form  no  inconsiderable  part  of  the  in- 
flammatory exudation.  As  the  colored  corpuscles  possess  only  limited  amoe- 
boid movements,  their  passage  through  the  capillary  wall  must  be  largely  a 
passive  process:  they  are  extruded  through  preformed  openings  or  through 
an  exceedingly  soft  cement-substance  by  the  intravascular  pressure.  It  is 
possible  that  they  are  forced  through  passages  made  by  the  emigration  cor- 


SYMPTOMS    OF    INFLAMMATION. 


115 


puscles.  It  is  well  known  that  at  first  only  leucocytes  are  found  outside  of 
the  capillary  vessels,  that  the  colored  corpuscles  appear  later,  and  that,  while 
leucocytes  also  pass  through  the  smallest  veins,  the  colored  corpuscles  escape 
only  through  capillary  vessels  (Fig.  68,  D). 

Arnold  noticed  that  red  corpuscles  floating  in  the  capillary  stream, 
when  they  arrived  opposite  a  stoma,  were  drawn  toward  the  opening  of  the 
transudation-stream. 

Diapedesis  becomes  a  prominent  feature  where  the  inflammatory  process 
is  very  acute,  consequently  where  extensive  alteration  of  the  vessel-walls  has 
taken  place.     In  such  instances  the  colored  corpuscles  are  so  numerous  in 


Fig.  68.— Inflammation  of  Frog's  Web  at  Stage  where  Capillary  Stream  is  Impeded 
by  Commencing  Emigration.  A,  small  artery;  B,  small  vein;  G,  capillaries;  D,  red 
corpuscles  which  have  escaped  from  capillary  by  diapedesis.     (Landerer.) 

the  exudation  as  to  impart  to  it  a  hsemorrhagic  appearance.  An  abundant 
escape  of  colored  corpuscles  in  inflammation  is  technically  called  rhexis. 
The  third  corpuscles  are  extruded  through  the  inflamed  capillary  wall  in  the 
same  passive  way  as  the  colored  corpuscles. 

The  primary  inflammatory  exudation  consists  of  the  corpuscular  ele- 
ments of  the  blood  which  escape  through  the  porous  capillary  wall,  the  prod- 
ucts of  their  disintegration,  and  blood-plasma.  The  latter  will  be  again 
referred  to  under  the  head  of  "Transudation."  The  presence  of  the  solid 
constituents  of  the  blood  differentiates  the  inflammatory  exudation  from  an 
ordinary  hydropic  or  oedematous  swelling.     The  question  arises:    What  be- 


116  PEINCIPLES    OF    SUEGERY. 

comes  of  the  corpuscular  elements  after  tliey  have  left  the  general  circula- 
tion? The  most  favorable  termination  of  the  inflammatory  process  consists 
in  the  preservation  of  the  vitality  of  the  cellular  elements  outside  of  the 
blood-vessels  and  their  return  into  the  general  circulation  by  a  process  which 
is  called  immigration.  This  probably  seldom,  if  ever,  takes  place  in  the  case 
of  the  colored  and  third  corpuscles,  which  undergo  molecular  disintegra- 
tion, and  the  granular  detritus  is  removed  by  absorption.  The  leucocytes 
which  have  retained  their  vitality  can  return  into  the  circulation  either  by 
reentering  the  capillaries  which  they  have  left,  after  the  acute  symptoms 
have  subsided  and  the  capillaries  have  been  cleared  of  the  mural  thrombi, 
or  by  a  more  indirect  route  through  the  lymphatic  vessels.  The  latter  route, 
is  probably  the  most  frequent.  If  the  blood-corpuscles  contain  the  microbic 
cause  of  the  inflammation  in  sufficient  quantity  and  intensity  to  destroy  their 
protoplasm,  they  furnish  the  necessary  nutrient  medium  for  the  growth  and 
development  of  the  microbe  outside  of  the  vessel-wall,  thus  bringing  it  in 
direct  contact  with  the  paravascular  tissues,  which  then  become  the  seat  of 
infection.  In  such  instances  the  cellular  elements  of  the  primary  inflam- 
matory exudation  are  dead  tissue,  and  act  or  are  disposed  of  as  such.  In 
acute  suppurative  inflammation  the  leucocytes  which  have  escaped  are  con- 
yerted  into  pus-corpuscles.  The  emigration  corpuscle  under  no  circumstances 
assumes  a  tissue- producing  function.  When  inflammatory  processes  result 
in  the  formation  of  new  tissue,  this  function  is  performed  by  fixed  tissue- 
cells  which  have  been  stimulated  to  a  state  of  activity  by  the  increased 
nutritive  conditions  incident  to  some  forms  of  inflammation.  The  albumen, 
which  is  always  present  in  considerable  quantity  in  every  inflammatory  exu- 
dation, furnishes  an  additional  nutrient  supply,  and  thus  assists  the  process 
of  cell-proliferation;  this  is  especially  the  case  with  the  globulins.  The 
filtrate  which  percolates  through  the  inflamed  capillary  wall  contains  co- 
agulable  substances,  which,  in  hydropic  fluids,  are  less  abundant.  The  emi- 
gration corpuscles,  which  disintegrate  soon  after  they  have  left  the  capillary 
vessels,  furnish  fibrin-ferment.  Fibrin-production  in  the  tissues  is  sus- 
pended as  soon  as  the  product  of  emigration  has  become  copious.  The  third 
corpuscles  furnish  another  source  of  fibrin-production.  In  suppurative  in- 
flammation fibrin-formation  does  not  take  place.  Where  no  fibrin  forms  in 
the  exudation,  the  supposition  lies  near  that  the  fibrin-producers  are  taken 
up  by  the  cells,  or  that  the  fibrin  which  had  already  been  produced  is  lique- 
fied and  assimilated  by  them.  If  the  inflamed  vessels  are  surrounded  only 
by  a  few  leucocytes,  the  latter  are  destroyed  and  liberate  fibrin-ferment;  if 
abundant,  they  are  more  resistant  and  destroy  albuminous  substances. 
Weigert  asserted  that  cell-necrosis  resulted  in  the  formation  of  fibrin,  as  the 
dead  cells  furnish  the  fibrin-ferment.  That  fibrin-production  does  not  al- 
ways attend  inflammation  can  only  be  explained  by  the  supposition  that  the 


SYMPTOMS    OF    INELAMMATION.  117 

fibrin-producers  are  assimilated  as  soon  as  they  have  left  the  blood-channels. 
If  the  cells  which  fnrnish  the  fibrin  come  in  contact  with  necrotic  tissue, 
such  an  assimilation  is  prevented  and  fibrin  is  formed.  Fibrin-production, 
however,  may  take  place  without  cell-necrosis,  as  is  the  case  upon  inflamed 
serous  surfaces.  Its  occurrence  in  this  particular  locality  can  only  be  ex- 
plained by  the  absence  of  accumulation  of  the  cells  which  yield  the  fibrin- 
ferment.  The  cellular  constituents  and  fibrin  of  the  inflammatory  exuda- 
tion impart  to  it  one  of  its  characteristic  clinical  features, — a  sense  of  firm- 
ness,— which  is  well  marked  in  proportion  to  the  predominance  of  these 
over  the  fluid  portion. 

2.  Infiammatory  Transudation. — The  liquid  portion  of  the  blood  which 
escapes  through  the  damaged  wall  of  inflamed  capillary  vessels  is  called  in- 
flammatory transudation.  The  same  causes  which  are  necessary  to  extrude 
the  non-amoeboid  corpuscular  elements  of  the  blood  constitute  also  the  con- 
ditions which  enable  a  part  of  the  blood-plasma  to  leave  the  capillary  stream. 
Increased  porosity  of  the  capillary  wall  is  the  most  important  of  them.  As 
soon  as  the  capillary  wall  has  become  abnormally  permeable  the" blood-press- 
ure forces  the  fluid  through  the  minute  pores  into  the  surrounding  con- 
nective tissue,  or,  if  the  inflammation  is  located  in  a  mucous  or  serous  mem- 
brane, upon  the  surface.  In  deep-seated  inflammation  the  transuded  fluid 
freely  percolates  through  the  connective-tissue  spaces,  and  gives  rise  to  one 
of  the  well-known  symptoms  of  inflammation:  the  inflammatory  oedema. 
The  transudation  is  always  more  widely  diffused  than  the  exudation.  Ee- 
cent  bacteriological  researches  have  shown  that,  while  in  the  tissues,  at  the 
seat  of  exudation,  the  presence  of  the  microbic  cause  of  the  inflammation  can 
be  readily  demonstrated  by  microscopical  examination  and  cultivation  ex- 
periments, the  oedema-fluid  some  distance  from  them  was  found  free  from 
microorganisms.  The  escape  of  blood-plasma  in  inflammation  is  a  process 
which  resembles  percolation  through  a  porous  membrane.  As.  the  blood- 
plasma  contains  fibrinogen  and  fibrinoplastic  material,  its  presence  in  the 
tissues  or  upon  inflamed  serous  or  mucous  membranes  is  important  in  the 
production  of  fibrin.  In  some  instances  the  inflammatory  product  is  greatly 
changed  by  the  presence  of  a  copious  transudation,  and  the  inflamed  part 
then  presents  more  the  appearance  of  oedema  than  inflammation.  This  is 
well  shown  b}^  the  two  clinical  varieties  of  anthrax.  The  expression  serous 
inflammation  is  used  to  indicate  the  predominance  of  transudation  over  exu- 
dation in  some  forms  of  inflammation.  The  liquid  transudate  predominates 
over  the  exudate  in  some  forms  of  sup]3urative  inflammation  (purulent 
oedema  of  Pirogoff),  also  when  the  circulation  is  feeble,  as  in  the  aged  and 
in  an?emic  individuals.  The  addition  of  mucus  alters  the  character  of  an 
exudation  or  a  transudation,  as  may  be  seen  when  a  mucous  membrane  is  the 
seat  of  inflammation.     Serous  transudation  often  precedes  mucous  exuda- 


118  PRINCIPLES    OF    SUKGEEY. 

tion,  as  in  cases  of  acute  catarrhal  inflammation  of  the  nasal  passages.  After 
the  acute  symptoms  of  inflammation  have  subsided  and  the  capillary  circula- 
tion has  been  restored,  the  transuded  fluid  is  absorbed,  and  with  its  absorp- 
tion the  inflammatory  oedema  disappears.  In  suppurative  inflammation  the 
transudation  becomes  the  pus-serum. 

(d)  Heat. — Increase  of  temperature  of  the  inflamed  part  is  the  result 
of  increased  afflux  of  blood  and  the  accompanying  augmentation  of  physio- 
logical processes.  Cohnheim  showed  experimentally  that  inflammation, 
without  an  increased  blood-supply,  does  not  give  rise  to  an  increase  of  tem- 
perature. John  Hunter  was  already  aware  that  the  temperature  at  the  seat 
of  inflammation  is  never  in  excess  of  the  temperature  of  the  blood.  Heat  is- 
both  a  subjective  and  objective  symptom.  In  acute  inflammation  of  the 
skin,  or  a  mucous  membrane,  the  patient  often  complains  of  a  distressing 
burning  or  scalding  sensation,  which  is  often  effectually  relieved  by  cold 
applications.  The  surface  thermometer  is  sometimes  an  important  instru- 
ment in  settling  a  differential  diagnosis  between  a  deeiD-seated  chronic  in- 
flammation and  a  malignant  tumor.  Diminution  of  temperature  may  in- 
dicate either  a  favorable  change  or  complete  arrest  of  circulation  in  the  in- 
flamed part,  in  the  first  instance  showing  that  resolution  is  in  progress,  in 
the  latter  announcing  the  speedy  occurrence  of  gangrene. 

(e)  Disturbance  of  Function. — As  inflammation,  wherever  it  occurs, 
consists  essentially  of  increased  nutritive  changes  in  the  tissues,  resulting 
in  consequence  of  a  more  abundant  blood-supply  and  an  exaggerated  vegeta- 
tive capacity  of  the  cells,  it  may  lead  to  at  least  a  temporary  increase  of  func- 
tion. This  is  always  the  case  in  inflammation  of  mucous  membranes,  where, 
as  one  of  the  prominent  clinical  features,  we  observe  an  increased  secretion 
of  mucus  usually  preceded  and  accompanied  by  a  more  or  less  profuse  tran- 
sudation. Parenchymatous  inflammation  in  glands  usually  produces  =udden 
diminution  and  often  complete  suppression  of  secretion.  Acute  suppurative 
osteomyelitis  is  attended  by  almost  complete  suspension  of  all  the  functions 
of  the  affected  limb.  Myositis  arrests  the  contractility  of  the  muscles  af- 
fected. The  pain  caused  by  an  inflammation  may  interfere  with  the  func- 
tions of  adjacent  organs,  as  may  be  seen  in  the  fixed  chest-wall  in  cases  of 
acute  pleuritis,  and  in  fixation  of  the  abdominal  walls,  with  diminished  or 
suspended  respiratory  movements  of  the  diaphragm,  in  cases  of  peritonitis. 
The  accumulation  of  inflammatory  products  may  prove  a  serious  obstacle 
to  important  functions,  and  often  constitutes  a  direct  cause  of  death,  as  in 
cases  of  intracranial  inflammation,  where  death  is  more  frequently  caused 
by  compression  of  the  brain  than  destruction  of  the  contents  of  the  cranial 
cavity;  and  the  accumulation  of  serum  or  pus  in  the  pleural  cavity  or  peri- 
cardium, where  a  fatal  termination  can  often  be  traced  to  mechanical  causes 
from  the  presence  of  a  copious  effusion.     Diminution  of  function  often 


SYMPTOMS    or    INFLAMMATIOiSr.  119 

affords  the  earliest  indication  of  the  existence  of  a  deep-seated  chronic  in- 
flammation, as  is  evident  from  the  slight  limp  which  ushers  in  a  coxitis  or 
the  imperfect  flexion  and  extension  in  chronic  inflammation  of  joints  other 
than  the  hip-joint. 


CHAPTEE  V. 

Inflammation  (continued). 

MODIFICATION    OF    INFLAMMATION    BY    THE    ANATOMICAL    STRUCTUEE 
AND    LOCATION    OF    THE    INFLAMED    TISSUE. 

The  clinical  course  and  pathological  conditions  of  inflammatory  proc- 
esses are  materially  modified,  not  only  by  the  primary  cause,  but  also  by 
the  anatomical  structure  and  location  of  the  inflamed  tissues.  Inflamma- 
tion of  serous  or  mucous  surfaces  has  a  tendency  to  spread  in  a  peripheral 
direction,  and,  as  a  rule,  remains  superficial,  and  the  exudation  and  tran- 
sudation are  poured  out  in  the  direction  offering  the  least  resistance;  that 
is,  upon  the  free  surface.  In  tissues  that  are  dense  and  unyielding  the 
swelling,  for  physical  reasons,  is  limited,  and  the  inflammatory  products  give 
rise  to  tension,  which  may  arrest  the  circulation  completely  and  cause  ne- 
crosis, as  is  the  case  in  acute  suppurative  osteomyelitis.  When  the  area  of 
inflammation  is  supplied  with  an  abundance  of  connective  tissue  the  swell- 
ing often  attains  enormous  dimensions  in  a  short  time,  as  may  be  seen  in 
every  case  of  phlegmonous  inflammation  of  the  deep-seated  connective  tis- 
sue of  the  extremities,  neck,  chest,  and  abdomen.  Acute  inflammation  of 
organs  that  are  exceedingly  vascular  gives  rise  to  an  early  and  abundant 
exudation,  as  can  be  demonstrated  in  every  case  of  croupous  pneumonia  and 
acute  nephritis.  Inflammation  of  non-vascular  tissue  is  accompanied  by  the 
formation  of  new  blood-vessels,  which  grow  in  the  direction  of  the  seat  of 
inflammation  from  the  nearest  vascular  district.  Some  tissues  are  more 
disposed  to  inflammation  than  others;  thus,  the  connective  tissue  is  more 
frequently  the  seat  of  acute  inflammation  than  muscles,  and  the  medullary 
tissue  than  the  bone-substance  proper,  and  most  causes  which  give  rise  to 
chronic  inflammation  are  known  to  select  certain  organs  and  tissues  in  prefer- 
ence to  others. 

PAEENCHTMATOUS    INFLAMMATION. 

In  the  study  of  the  cardinal  symptoms  of  inflammation  special  atten- 
tion was  given  to  the  part  taken  in  the  inflammatory  process  by  the  capil- 
lary vessels  and  the  blood-corpuscles.  Alteration  of  the  capillary  wall  was 
alluded  to  as  the  most  important  pathological  condition,  as  upon  it  depends 
the  emigration  of  the  corpuscular  elements  of  the  blood  and  the  occurrence 
of  the  inflammatory  transudation,  which  together  constitute  the  primary 
inflammatory  swelling.  Incidentally  it  was  stated  that,  as  soon  as  the  cause 
which  gave  rise  to  the  inflammation  is  brought  in  direct  contact  with  the 

(120) 


PAEENCHYMATOUS    INFLAMMATION.  121 

fixed  tissue-cells,  these  take  part  in  the  inflammatory  process  and  contribute 
their  share  to  the  inflammatory  exudation.  Inflammation  is  said  to  be 
parenchymatous  when  the  parenchyma  of  an  organ  is  the  primary  seat  of 
inflammatory  changes,  as  when  the  secreting  structures  of  a  gland  are  im- 
plicated from  the  beginning.  In  all  such  instances  the  blood-vessels  which 
furnish  the  vascular  supply  have  undergone  the  characteristic  changes  which 
have  been  described,  and  with  few  exceptions  the  microbes  have  been  con- 
veyed to  the  parenchyma  through  them.  The  cloudy  swelling  of  paren- 
chyma-cells is  either  an  evidence  of  the  existence  of  degenerative  changes  or 
it  denotes  the  beginning  of  coagulation-necrosis  from  the  specific  effect  of 
pathogenic  microbes  upon  their  protoplasm.  A  cloudy  appearance  of  cells 
is  one  of  the  first  manifestations  of  the  presence  of  a  parenchymatous  in- 
flammation. Lesion  of  connective-tissue  or  parenchyma-  cells  is  next  to 
alteration  of  the  capillary  wall,  and  emigration  of  the  blood-corpuscles  the 
most  important  pathological  condition  of  inflammation,  and,  as  far  as  the 
ultimate  result  is  concerned,  the  most  important,  as  extensive  destruction 
of  parenchyma-cells  will  result  in  suspension  of  function,  and  death  of  the 
organ  aff'ected.  As  soon  as  the  fixed  tissue-cells  outside  of  the  vessel-wall 
have  become  implicated  their  physiological  resistance  is  diminished:  a 
condition  which  cannot  fail  in  aggravating  the  existing  vascular  disturb- 
ances. Landerer  maintains  that  the  normal  elasticity  of  the  tissues  sur- 
rounding the  capillary  vessels  is  an  essential  factor  in  preserving  the 
equilibrium  between  the  intravascular  pressure  and  the  surrounding  tissues 
in  a  normal  condition  of  the  circulation.  This  mechanical  theory  of  inflam- 
mation is  founded  upon  the  supposition  that  this  normal  elasticity  of  the 
paravascular  tissues  is  diminished  by  the  causes  which  give  rise  to  inflam- 
mation, and  that  when  this  has  occurred  the  capillary  walls  have  lost 
their  outer  support,  in  consequence  of  which  they  become  dilated,  and 
hypergemia,  slowing  of  blood-current,  emigration,  and  transudation  fol- 
low as  the  result  of  purely  mechanical  causes.  Ingenious  as  this  theory 
may  appear,  it  cannot  explain  the  complicated  processes  which  characterize 
inflammation.  The  train  of  pathological  conditions  ivhich  attend  inflamma- 
tion must  he  regarded  as  effects  of  a  common  microhic  cause  upon  the  capil- 
lary wall,  their  contents,  and  the  flxed  tissue-cells  outside  of  the  capillary 
vessels.  In  parenchymatous  inflammation  the  cause  has  reached  the 
parenchyma-cells,  either  directly,  as  when  microbes  are  brought  in  con- 
tact with  a  mucous  surface,  become  attached  to  and  penetrate  the  paren- 
chyma-cells, multiply  in  their  interior,  and,  later,  reach  the  connective  tis- 
sue and  blood-vessels,  or,  what  is  more  common,  the  microbes  reach  the 
parenchyma  through  the  circulation.  In  both  instances  the  capillary  ves- 
sels and  the  connective  tissues  between  them  and  the  parenchyma-cells  take 
an  active  part  in  the  inflammatory  process.     The  microbes  may  be  present 


122  PEINCIPLES    OF    SURGERY. 

in  such  great  number  or  may  possess  such  intensely  virulent  properties  as  to 
destroy  the  parenchyma-cells^,  as  is  the  case  in  diphtheritic  inflammation  of 
mucous  membranes.  When  less  intense  in  their  action  the  parenchyma-cells 
proliferate,  and  the  embryonal  cells,  being  less  resistant,  succumb  later,  as 
when  suppuration  occurs  in  the  parenchyma  of  an  organ,  or  they  remain  in- 
definitely in  their  embryonal  state,  as  can  be  readily  verified  by  examining 
the  different  forms  of  chronic  inflammatory  swelling:  the  so-called  granulo- 
mata. 

INTERSTITIAL    INFLAMMATION. 

In  this  form  of  inflammation  the  connective  tissue  is  the  primary  seat  of 
cell-emigration  and  tissue-proliferation.  Many  of  the  microbes  select  the 
connective-tissue  spaces;  they  locate  and  multiply  here,  and  the  inflamma- 
tory product  is  composed  almost  exclusively  of  emigration-corpuscles  and 
embryonal  connective-tissue  cells.  Tubercle  and  gummata  present  such  a 
histological  structure.  Phlegmonous  inflammation  represents  the  acute  form 
of  connective-tissue  inflammation.  If  the  connective  tissue  of  an  organ 
becomes  the  seat  of  an  inflammatory  hyperplasia  the  parenchyma  suffers, 
either  in  consequence  of  pressure  or,  later,  from  cicatricial  contraction  and 
the  inevitable  diminution  of  blood-supply  incident  to  this  condition.  Paren- 
chymatous inflammation  of  an  organ  is  preceded  or  followed  by  interstitial 
inflammation,  and  a  primarily  interstitial  inflammation  sooner  or  later  in- 
volves the  surrounding  tissue  by  direct  extension  of  the  inflammatory  proc- 
ess, or  indirectly  by  the  mechanical  causes;  hence,  as  a  rule,  it  is  anatomic- 
ally and  even  etiologieally  not  always  possible  to  differentiate  between  these 
two  forms  of  inflammation,  nor  is  such  a  distinction  of  much  practical  im- 
portance. 

HJEMORRHAGIC    INFLAMMATION. 

A  few  colored  corpuscles  escape  through  the  capillary  wall  in  almost 
every  case  of  acute  inflammation,  but  their  presence  in  the  exudation  can 
only  be  determined  by  the  use  of  the  microscope.  When  they  are  present 
in  sufficient  number  to  impart  to  the  exudation  a  bloody  tinge,  we  speak 
of  a  hasmorrhagic  exudation  or  transudation.  A  hsemorrhagic  transudation 
into  the  pleural,  pericardial,  or  peritoneal  cavity  usually  indicates  the  ex- 
istence of  a  tubercular  or  malignant  disease  of  the  respective  serous  mem- 
branes. In  cases  of  acute  inflammation  with  hsemorrhagic  exudation,  the 
quantity  of  the  effused  blood  will  be  a  sign  by  which  we  can  at  least  approxi- 
mately estimate  the  extent  of  alteration  of  the  capillary  wall.  Ehexis  can 
only  take  place  when  the  capillary  wall  at  some  point  has  been  completely 
broken  down  and  an  opening  of  considerable  size  has  formed  through  which 
a  small  stream  from  the  axial  current  can  escape.    Aside  of  the  nature  and 


INFLAMMATION    OF    SEROUS    MEMBRANES.  123 

intensity  of  the  primary  cause  of  the  inflammation,  hsemorrhagic  inflamma- 
tion is  more  likely  to  be  met  Avith  in  persons  debilitated  from  other  diseases, 
in  the  aged,  and  in  patients  suffering  from  diseases  which  obstruct  the  cir- 
culation, such  as  valvular  disease  of  the  heart,  cirrhosis  of  the  liver,  em- 
physema of  the  lungs,  and  chronic  affections  of  the  kidneys.  The  presence 
of  blood  in  a  transudation  or  exudation  is  always  a  grave  sign,  and  as  such 
should  ahvays  be  taken  into  careful  consideration  in  rendering  a  prognosis. 

SUPPURATIVE    INFLAMMATION. 

In  suppurative  inflammation  at  least  a  part  of  the  exudation  is  trans- 
formed into  pus.  Transformation  of  the  cellular  portion  of  the  exudation, 
the  leucocytes  and  embryonal  cells,  into  pus-corpuscles  is  due  to  the  de- 
structive effect  upon  their  protoplasm  of  the  pus-microbes  and  their  tox- 
ins, while  the  transudate  becomes  the  pus-serum.  Suppurative  inflam- 
mation occurs  either  as  the  result  of  a  primary  or  secondary  infection  with 
pus-microbes.  In  primary  infection  with  pus-microbes  the  leucocytes  most 
remote  from  the  blood-vessels,  and  which  have  been  exposed  longest  to  the 
specific  action  of  the  pus-microbes  and  their  toxins,  are  converted  first 
into  pus-corpuscles,  while  the  fixed  tissue-cells  are  first  transformed  into 
embryonal  cells  before  the  same  cause — by  destruction  of  their  protoplasm^ 
changes  them  into  similar  structures.  In  suppurative  inflammation  due  to 
secondary  infection  the  pus-microbes  act  upon  embryonal  cells  which  owe 
their  origin  to  an  antecedent  infection  with  another  microbe  of  milder 
pathogenic  qualities,  as  can  be  seen  Avhen  tubercular  granulations  or  a 
gumma  undergo  suppuration.  Suppurative  inflammation,  in  all  of  its  as- 
pects, will  be  fully  considered  in  the  chapter  on  "Suppuration." 

INFLAMMATION    OF    SEROUS    MEMBRANES. 

Inflammation  of  the  serous  membranes  has  been  called  exudative,  ad- 
hesive, suppurative,  or  serous,  according  to  the  character  of  the  inflamma- 
tory product.  In  most  inflammatory  affections  of  the  serous  membranes 
the  surface  becomes  covered  with  a  copious  exudation,  which  is  composed 
of  leucocytes,  fibrin,  and  the  products  of  tissue-proliferation  of  the  endo- 
thelial and  connective-tissue  cells.  The  leucocytes  and  third  corpuscles  are 
rapidly  destroyed  as  they  reach  the  surface,  and  the  fibrin-ferment  and 
fibrinoplastic  material  which  are  liberated  form — on  combining  with  the 
fibrinogen  of  the  blood-plasma — fibrin.  The  infiamed  membrane  is  often 
covered  by  a  thick  layer  of  fibrin,  which  is  firmly  adherent  to  the  surface 
by  means  of  new  blood-vessels  and  granulation-tissue  which  have  grown  into 
it.  The  endothelial  cells  take  an  active  part  in  the  inflammation,  and  in  case 
the  new  product  froui  this  source  is  converted  into  connective  tissue  a  per- 


124 


PEIXCIPLES    OF    SUEGEBY. 


manent  adhesion  forms.  In  some  instances  the  endothelial  cells  are  de- 
stroyed and  desquamation  takes  place^  which  leaves  the  subjacent  connective 
tissue  exposed.  In  such  cases  the  superficial  dilated  capillaries  have  lost  an 
important  support,  and  transudation  takes  place  freely.  D.  J.  Hamilton  -has 
studied  the  histological  changes  which  occur  in  peritonitis  by  producing  this 
disease  artificially  in  young  dogS;  Besides  desquamation,  he  has  seen  the 
endothelial  cells  multiply  by  division  of  the  nucleus. 


Fig.  69. — Germinating  Endothelium,  Omentum  of  Young  Dog.  Acute  Peritonitis. 
Silver  Staining.  X  350.  A,  natural  endothelium  covering  wall  of  a  mesh;  B,  D,  endo- 
thelial cells  beginning  to  germinate;  C,  a  chain  of  germinating  cells  extending  across  a 
fenestra;    E,  mass  of  germinating  endothelial  cells.     (Uumilton.) 

The  ncAv  cells  resemble  the  ordinary  granulation  or  embryonal  cells. 
The  connective  tissue  between  the  endothelial  lining  and  the  blood-vessels 
undergoes  tissue-proliferation,  and  the  new  cells  reach  the  surface  and  min- 
gle with  those  derived  from  the  endothelial  lining,  so  that  the  inflamed  sur- 
face becomes  covered  with  a  layer  of  granulation-tissue.  The  granulations, 
accompanied  by  dilated  or  new  blood-vessels,  penetrate  into  the  fibrinous 


INFLAMMATION    OF    SEROUS    MEMBEANES. 


125 


exudation,  which  is  removed  in  the  same  manner  as  a  thrombns  in  a  blood- 
vessel nndergoing  obliteration.  Permanent  adhesions  and  obliteration  of 
serons  cavities  are  effected  by  the  granulation-tissue,  which  removes  the  in- 
flammatory exudation  and  establishes  an  organic  union  between  opposing 


■pie-  70— Omentum  of  Young  Dog,  Experimentally  Inflamed.  X  450.  .1,  pyriform 
cell  probably  of  endothelial  origin,  sprouting  from  wall  of  a  fenestra  (S)  of  the  mem- 
brane^ C  capillary,  surrounded  by  extravasated  leucocytes;  V,  small  vem,  m  similar 
condition.'    {Hamilton.) 

inflamed  membranes.  If  the  fixed  tissue-cells  do  not  participate  actively  in 
the  inflammatory  process,  the  exudation  becomes  absorbed  in  the  course  of 
time,  and  the  endothelial  lining  is  repaired;  thus  the  temporary  adhesions 
are  removed,  and  the  normal  relations  existing  between  the  serous  membrane 
and  inclosed  viscera  are  restored.    The  blending  of  the  corpuscular  elements 


126 


PRINCIPLES    OF    SUEGEEY. 


of  the  inflammatory  exudation  of  a  serous  membrane  with  the  product  of 
tissue-proHferation  of  the  endothelial  cells  is  well  shown  in  Fig.  70. 

The  pathological  anatomy  of  acute  inflammation  of  a  serous  membrane 
at  an  early  stage  is  well  represented  in  Fig.  71. 

The  scarcity  of  leucocytes  in  the  fibrin  in  the  specimen  represented  by 
this  illustration  was  undoubtedly  due  to  their  rapid  destruction  as  soon  as 
they  reached  the  surface,  which  resulted  in  the  formation  of  a  copious  de- 
posit of  fibrin.     The  round  cells  in  the  subpleural  connective  tissue  are 


Fig.  71. — Acute  Pleurisy.  X  300.  A,  A,  net-worlc  of  flbrin;  B,  an  effused  leucocyte; 
C,  laminae  of  fibrin  lying  adjacent  to  the  pleura  (F) ;  D,  small  round  cells  effused  into 
the  pleura;    E,  distended  blood-vessel  of  the  superficial  layer  of  pleura.    {Hamilton.) 

wandering  leucocytes.  Sufficient  time  does  not  seem  to  have  elapsed  for  any 
marked  changes  to  have  occurred  in  the  fixed  tissue-cells.  In  suppurative 
inflammation  of  a  serous  membrane,  if  life  is  sufficiently  prolonged,  the 
leucocytes  and  embryonal  cells  are  transformed  into  pus-corpuscles,  and  in 
this  manner  empyema,  pyocardium,  and  purulent  peritonitis  are  produced. 
The  introduction  of  pus-microbes  in  sufficient  quantity  into  the  abdominal 
cavity,  the  power  of  absorption  of  which  has  been  reduced  by  an  antecedent 
affection  or  an  accompanying  trauma.,  will  produce  such  a  rapidly  fatal 


IN-FLAMMATION    OF    MUCOUS    MEMBEANES.  137 

peritonitis  that  the  peritoneum,  on  post-mortem  examination,  will  show 
little,  if  any,  macroscopical  lesions.    Death  in  such  cases  results  from  acute 
septic  infection.    When  life  is  prolonged  for  several  days,  the  post-mortem 
reveals  all  the  evidences  of  a  fibrinoplastic  peritonitis;    that  is,  numerous 
adhesions  between  the  intestines  and  the  parietal  peritoneum  and  among  the 
intestinal  loops.    In  suppurative  peritonitis  the  exudation  often  breaks  down 
as  the  leucocytes  contained  in  it  are  converted  into  pus-corpuscles.     Tuber- 
cular peritonitis  is  usually  attended  by  a  copious  exudation,  which  limits  the 
process  and  encapsulates  the  serous  transudation.     If,  in  an  inflammation 
of  a  serous  membrane,  the  transudation  predominates  over  the  exudation, 
the  character  of  the  process  is  indicated  clinically  by  a  subacute  or  chronic 
course  and  the  absence  of  severe  symptoms.     Hydrothorax  often  develops 
insidiously,  and  perhaps  the  first  subjective  symptom  is  difficulty  of  breath- 
ing.    Tubercular  peritonitis  with  copious  circumscribed  effusion  has  been 
frequently  mistaken  for  ovarian  cyst,  not  only  because  the  swelling  closely 
resembles  a  unilocular  ovarian  cyst,  but  also  from  the  absence  of  any  of  the 
usual  local  symptoms  which  attend  the  different  forms  of  fibrinoplastic  peri- 
tonitis.   It  appears  that  the  causes  which  give  rise  to  this  form  of  inflamma- 
tion of  serous  membranes  do  not  act  with  sufficient  intensity  on  the  capil- 
lary wall  and  the  paravascular  tissues  to  provoke  a  copious  exudation  and 
active  tissue-proliferation,  but  create  conditions  which  permit  a  copious 
transudation  to  take  place.    It  has  been  recently  a  much-discussed  question 
whether  or  not  all  cases  of  serous  effusion  into  the  chest  are  of  tubercular 
origin.    The  fact  remains  that  many  cases  of  subacute  and  chronic  pleurisy 
die  subsequently  from  tuberculosis,  and  the  natural  conclusion  would  be  that 
the  disease  was  primarily  caused  by  a  localized  tubercular  focus,  which,  at  the 
time,  could  not  be  detected.     It  is  evident  that  the  causes  which  produce 
serous  transudation  do  so  not  only  by  producing  changes  in  the  capillary  wall 
which  permit  free  transudation,  but  also  by  bringing  about  alterations  which 
diminish  or  completely  suspend  the  power  of  absorption;  heiice,  not  only  the 
occurrence  of  transudation,  but  accumulation  of  the  liquid  effused.     The 
presence  of  blood  in  the  transudation  is  usually  an  indication  of  the  presence 
of  tuberculosis,  carcinoma,  or  sarcoma. 

INFLAMMATIOISr    OF    MUCOUS    MEMBEANES. 

Inflammation  of  a  mucous  membrane  represents  another  variety  of  sur- 
face inflammation  which  is  greatly  modified  by  the  anatomical  character  of 
the  tissue  the  seat  of  the  inflammatory  process.  We  have  seen  that  inflam- 
mation of  serous  membranes  presents  as  its  most  characteristic  pathological 
feature  a  plastic  exudation  on  its  surface,  composed  of  escaped  blood- 
corpuscles  and  the  products  of  their  disintegration,  which  are  firmly  attached 
to  the  endothelial  lining,  which,  in  part,  has  been  destroyed  and  detached 


128  PEINCIPLES    OF    SURGERY. 

by  desquamation,  while  the  cells  which  have  retained  their  vitality  proliferate 
new  tissue,  which  mingles  with  and  ultimately  removes  the  exudation.  The 
epithelial  cells  which  line  mucous  membranes  when  in  a  state  of  inflamma- 
tion are  stimulated  to  increased  activity,  and  consequently  secrete  an  in- 
creased quantity  of  mucus,  Avhich  is  the  characteristic  pathological  and  clin- 
ical feature  of 

I.    CATARRHAL    INFLAMMATION. 

Inflammation  of  a  mucous  membrane  is  called  catarrhal  as  long  as  the 
product  consists  of  an  increased  secretion  of  mucus.  If  a  part  of  the  mucous 
lining  is  destroyed  and  the  discharge  becomes  a  mixture  of  pus  and  mucus, 
it  is  no  longer  proper  to  call  it  a  catarrhal  inflammation,  as  the  pus-microbes 
have  wrought  changes  that  bring  the  process  within  the  legitimate  sphere 
of  suppurative  inflammation.  Catarrhal  inflammation  produces  a  thicken- 
ing of  the  mucous  membrane  by  infiltration  of  the  submucous  tissue,  which, 
if  copious,  may  subsequently  give  rise  to  cicatricial  contraction,  and,  if  the 
inflammation  is  located  in-  a  tubular  organ,  to  the  formation  of  strictures. ' 
According  to  Virchow,  a  catarrhal  inflammation  may  lead  to  the  formation 
of  superficial  ulcers, — the  so-called  catarrhal  ulcers. 

II.    SUPPURATIVE    INFLAMMATION. 

In  this  form  of  inflammation  of  a  mucous  membrane,  the  leucocytes 
wdiich  reach  its  surface,  as  well  as  the  embryonal  cells,  are  destroyed  by 
the  pus-microbes  and  are  converted  into  pus-corpuscles,  which  when 
mixed  with  the  mucus  secreted  by  the  cells  which  have  retained  their 
physiological  function,  form  the  muco-purulent  discharge.  Most  of  the 
ulcers  which  form  upon  mucous  surfaces  result  from  circumscribed  necrosis 
or  suppurative  inflammation.  A  catarrhal  inflammation  very  frequently 
precedes  the  suppurative  form,  and  a  circumscribed  suppurating  area  is  usu- 
ally surrounded  by  a  zone  of  catarrhal  inflammation.  'Cicatricial  oblitera- 
tion of  a  tubular  organ  can  only  take  place  after  extensive  defects  of  its 
mucous  lining  from  necrotic,  ulcerative,  or  traumatic  causes.  Limited  defects 
are  repaired  by  regeneration  of  the  epithelial  cells,  either  from  the  margins 
of  the  defect  or  from  remnants  of  glands.  The  most  frequent  causes  of 
ulceration  in  the  intestinal  canal  are  dysentery,  typhoid  fever,  and  tuber- 
culosis. Ulcers  which  result  from  the  sudden  obliteration  of  a  small  blood- 
vessel by  thrombosis  or  embolism  are  met  with  after  extensive  burns  in  the 
upper  portion  of  the  small  intestine  and  in  the  stomach  in  chlorotic  females. 
A  strange  form  of  perforative  enteritis  has  recently  been  described  by 
Mikulicz.  A  similar  case  was  operated  on  in  the  Zurich  Klinik,  and  a  care- 
ful description  of  the  pathological  conditions  found  at  the  necropsy  has  been 
given  by  Klebs.    He  found  multiple  perforations  in  a  circumscribed  portion 


INFLAMMATION    OF    MUCOUS    MEMBRANES.  129 

of  the  jejunum,  and  only  a  few  of  them  had  been  found  and  closed  by  the 
surgeon  who  performed  the  operation.  The  perforations  on  the  peritoneal 
side  were  covered  by  a  plastic  exudation.  The  lumen  of  the  intestine  corre- 
sponding to  the  affected  portion  was  considerably  enlarged.  Mucous  mem- 
brane not  much  changed  in  appearance,  but,  on  close  inspection,  a  number 
of  small  defects,  partly  hidden  under  the  folds,  were  detected,  and  were  found 
to  correspond  with  the  covered  defects  on  the  outer  surface.  On  micro- 
scopical examination,  it  was  found  that  the  villi  and  mucous  membrane  were 
softened  and  denuded  of  the  epithelial  lining  and  infiltrated  with  cells  over 
a  considerable  distance  beyond  the  perforations.  The  most  marked  changes 
were  found  in  the  submucous  tissue,  which  was  also  much  softened,  and  the 
scanty  intercellular  substance  was  found  traversed  by  wide  spaces  in  which 
were  found  numerous  large  cells  with  large  oval  nuclei.  Besides  these  en- 
larged parenchyma-cells,  and  in  their  vicinity,  leucocytes  which  had  under- 
gone fragmentation  were  found.  As  the  capillary  vessels  were  much  dilated 
and  in  a  condition  of  inflammation,  Klebs  looks  upon  the  process  as  an  hy- 
perplastic parenchymatous  enteritis.  As  the  leucocytes  found  in  the  tissues 
presented  all  the  evidences  of  fragmentation,  there  can  be  but  little  doubt 
that  this  rare  form  of  enteritis  presents  only  another  variety  of  suppurative 
inflammation  of  the  mucous  membrane  of  the  intestine. 

III.    CEOUPOUS    INFLAMMATION. 

When  inflammation  of  a  mucous  membrane  is  attended  by  the  formation 
of  a  fibrinous  exudation  or  false  membrane  upon  its  surface,  it  is  called 
croupous.  The  formation  of  a  fibrinous  exudation  upon  a  serous  surface,  we 
have  found,  is  always  associated  with  a  more  or  less  extensive  destruction 
and  desquamation  of  endothelial  cells,  and  a  similar  superficial  change  takes 
place  in  croupous  infiammation.  Weigert  states  that  unless  the  epithelial 
surface  of  a  mucous  membrane  be  broken  the  inflammatory  exudation  from 
it  will  not  coagulate.  As  croupous  inflammation  of  a  mucous  membrane  is 
always  produced  by  direct  infection,  it  is  probable  that  the  microorganisms 
destroy  some  of  the  epithelial  cells;  and  as  the  inflammatory  process  pene- 
trates deeper  into  the  tissue,  the  exudation  and  transudation  coming  in  con- 
tact with  dead  tissue  on  the  surface,  fibrin  is  deposited,  and,  becoming  en- 
tangled with  the  cellular  dehris,  it  becomes  adherent  to  the  partially-abraded 
and  uneven  surface.  The  fibrin  is  arranged  in  layers  in  the  form  of  a  coarse 
net-work,  in  the  meshes  of  which  is  a  finer  reticulum  of  the  same,  with  leu- 
cocytes and  embryonal  cells  thrown  ofi:  from  the  surface.  Some  membranes 
contain  numerous  leucocytes,  while  in  others  they  are  destroyed  in  the  proc- 
ess of  coagulation.  Separation  of  a  false  membrane  takes  place  either  by 
the  mucus  secreted  by  intact  cells  underneath  it,  or,  if  the  mucous  lining  has 


130  PKINCIPLES    OF    SUEGEEY. 

been  completely  destroyed;,  by  suppuration  and  granulation.  It  has  been 
claimed  that,  pathologically,  a  croupous  membrane  differs  from  a  diph- 
theritic exudation  in  that  in  the  former  the  lining  of  the  mucous  membrane 
is  found  intact  after  stripping  it  off,  while  in  a  diphtheritic  inflammation 
there  is  always  found  a  loss  of  surface  substance  after  removing  the  mem- 
brane. Upon  this  more  apparent  than  real  anatomical  difference  the  dis- 
cussion on  the  non-identity  of  croupous  and  diphtheritic  inflammation  rests. 
As  superficial  coagulation-necrosis  is  present  in  all  cases  of  croupous  inflam- 
mation, and  if  this  process  is  etiologically  different  from  diphtheritic  inflam- 
mation, the  pathological  conditions  are  different  only  in  degree,  and  not  in 
kind.  False  membranes,  wherever  they  may  form  upon  a  mucous  or  serous 
surface,  serve  as  nutrient  media  for  microorganisms,  and  the  underlying  sur- 
face is  subjected  to  the  risks  of  recurring  infection  from  them  as  long  as 
they  remain. 

IV.    DIPHTHEEITIC    INFLAMMATION. 

Diphtheritic  inflammation  is  caused  by  the  Klebs-LofEler  bacillus.  As 
a  primary  disease  it  affects  most  frequently  the  upper  part  of  the  respiratory 
tract.  Extensive  destruction  of  the  mucous  membrane  underneath  the  exu- 
dation is  a  constant  occurrence.  Diphtheritic  inflammation  is  frequently 
complicated  by  secondary  infection  with  pus-microbes  and  saprophytes: 
an  occurrence  which  greatly  aggravates  the  local  conditions  and  increases 
the  danger  to  life. 

INFLAMMATION    OF    NON-VASCULAE    TISSUE. 

The  importance  of  blood-vessels  in  inflammation  can  be  best  shown  by 
a  study  of  the  pathological  conditions  in  inflammation  of  non-vascular  tis- 
sue. The  part  taken  by  the  blood-vessels  and  the  fixed  tissue-cells  in  the 
inflammatory  process  can  be  most  satisfactorily  demonstrated  in  non-vas- 
cular organs. 

Cornea. — Cohnheim  first  demonstrated  emigration  of  the  colorless 
blood-corpuscles  in  artificially-produced  keratitis.  He  cauterized  the  cornea 
in  animals,  and  then  observed  cell-infiltration  from  its  margins  at  a  point 
corresponding  to  the  nearest  vascular  supply.  For  the  purpose  of  showing 
that  the  cells  were  not  products  of  the  fixed  tissue-cells  he  injected,  a  few 
days  before  cauterization,  finely-divided  cinnabar  into  the  circulation,  and 
found  that  the  leucocytes,  as  they  escaped  from  the  capillary  vessels,  con- 
tained granules  of  the  pigment  which  he  had  injected.  The  leucocytes  were 
seen  to  wander  through  the  vascular  spaces  of  the  cornea  toward  the  seat 
of  cauterization.  As  he  could  observe  no  changes  in  the  fixed  corneal  cor- 
puscles at  the  seat  of  cauterization,  he  maintained  that  the  inflammatory 
product  was  derived  exclusively  from  the  blood,  and  that  its  escape  from  the 


INFLAMMATION    OF    NON-VASCULAR   TISSUE.  131 

blood-streams  depended  on  alteration  of  the  capillary  wall.  He  regarded 
the  dilatation  of  blood-vessels,  which  occurs  soon  after  the  application  of 
the  irritant,  as  a  result  of  reflex  action,  and  attempted  to  prove,  by  specimens 
of  keratitis  stained  with  chloride  of  gold,  that  the  fixed  tissue-cells  remained 
unaffected  by  the  inflammation.  Strieker  maintained  the  opposite  view,  and 
proved,  in  silver-stained  specimens,  that  the  corneal  corpuscles  had  under- 
gone changes  which  indicated  that  they  performed  an  active  part  in  the  in- 
flammation. Kecklinghausen  resorted  to  a  very  ingenious  experiment  to 
establish  his  theory  regarding  the  origin  of  the  wandering  cells  in  the  vas- 
cular spaces  of  the  cornea.  He  cauterized  the  cornea  of  a  frog,  excised  it 
immediately,  and  kept  it  under  conditions  favorable  to  cell-vegetation,  and 
found,  later,  wandering  cells  in  the  vascular  spaces,  the  origin  of  which  he 
traced  to  tissue-proliferation  of  the  corneal  corpuscles  after  excision;  but 
even  his  assistant,  F.  A.  Hoffmann,  expressed  the  opinion  that  the  cells 
might  have  been  leucocytes  which  had  entered  the  vascular  spaces  before  the 
cornea  was  excised.  It  is  more  than  doubtful  that  tissue-proliferation  would 
take  place  in  an  excised  cornea,  even  under  the  most  favorable  physical  con- 
ditions. There  can  be  no  doubt,  whatever  that  the  primary  exudation  in 
traumatic  keratitis,  as  in  all  other  forms  of  acute  inflammation,  takes  place 
from  inflamed  capillary  vessels,  as  Cohnheim  has  demonstrated  so  beauti- 
fully; but  this  constitutes  only  a  part  of  the  phenomena  which  characterize 
inflammation  in  the  cornea  and  all  other  tissues,  as,  later,  the  fixed  tissue- 
cells  participate  in  the  process,  and  the  new  cells  derived  from  them  form  a 
part  of  the  inflammatory  products.  The  parenchymatous  changes  are  even 
more  important  than  the  vascular,  as  repair  after  subsidence  of  inflamma- 
.tion  is  accomplished  exclusively  by  proliferation  of  the  fixed  tissue-cells. 
Eberth  has  demonstrated,  by  his  accurate  histological  researches,  that  the 
corneal  corpuscles  near  an  eschar,  made  for  the  purpose  of  producing  a 
keratitis,  multiply  by  karyokinesis,  and  regeneration  is  effected  exclusively 
by  the  embryonal  cells  derived  from  this  source.  The  corneal  corpuscles 
possess  a  high  vegetative  capacity — resembling  in  this  respect  the  connective 
tissue,  to  which  they  bear  a  strong  resemblance,  having  a  similar  embryo- 
logical  origin — and  receive  their  nutritive  supply  through  a  system  of  lymph- 
channels  or  vascular  spaces  which  are  in  intimate  relationship  with  the  scle- 
rotic vessels  at  the  border  of  the  cornea.  The  plasma-  or  lymph-  channels  in 
the  cornea  are  loosely  filled  with  a  liquid  albuminoid  substance,  in  Avhich 
can  be  seen,  even  in  a  normal  condition,  occasionally,  a  lymph-corpuscle.  In 
artificial  keratitis  these  channels  are  first  packed  with  leucocytes,  which 
escape  from  the  congested  capillaries  at  the  limbus  cornese,  enter  them 
directly,  and  wander  toward  the  seat  of  irritation  far  in  advance  of  the  new 
blood-vessels.  Infiltration  of  the  cornea  with  leucocytes  gives  rise  to  cloudi- 
ness.   At  first  Cohnheim  claimed  that  infiltration  of  the  cornea  always  oc- 


132  PEINCIPLES    OF    SUKGERY. 

curred  from  the  periphery,  but  in  some  of  the  later  experiments  on  the 
cornege  of  spring  frogs  he  noticed  cell-accumulation  around  the  central 
eschar  made  with  a  sharp  pencil  of  nitrate  of  silver,  and,  as  he  was  absolutely 
opposed  to  the  idea  that  the  corneal  corpuscles  could  take  any  active  part 
in  the  process,  he  came  to  the  forced  conclusion  that  the  cellular  elements 
of  the  conjunctival  fluid  were  increased,  and  that  these  had  wandered  into 
the  cornea  through  the  lesion  at  the  centre.  Strieker  has  observed  karyo- 
mitotic  changes  in  the  corneal  corpuscles  surrounding  a  central  eschar  as 
early  as  three  hours  after  cauterization,  and,  after  twenty-four  to  forty-eight 
hours,  cell-proliferation  was  seen  to  be  present  all  around  the  inflamed  area. 
From  what  different  authors  have  written  on  the  subject  of  artificial 
keratitis, — which,  of  course,  must  be  accepted  as  a  fair  representative  of  the 
clinical  forms  of  this  disease, — it  becomes  apparent  that  the  first  evidence  of 
inflammation  is  an  increased  amount  of  fluid  in  the  vascular  spaces,  causing 
distension  and,  consequently,  swelling  of  the  cornea.  As  the  plasma-canals 
become  distended,  the  cells  lining  them  are,  in  part,  destroyed,  and  the  fluid 
escapes  between  two  laminas  and  forces  them  partly  asunder.  (Fig.  72,  G,  C.) 
At  this  time  the  endothelial  cells  and  corneal  corpuscles  undergo  tissue- 
proliferation,  and  the  new  cells  form  part  of  the  inflammatory  product.  With 
the  breaking  down  of  the  vascular  spaces  resulting  in  lymph-stasis,  accumti- 
lation  of  lymph-corpuscles  also  takes  place,  by  which  another  cellular  ele- 
ment is  added  to  the  inflammatory  product.  The  plasma-channels  and  arti- 
ficially-formed spaces  between  laminae  are  now  blocked  with  leucocytes, 
lymph-corpuscles,  and  embryonal  cells.  If  the  irritation  is  prolonged  for  a 
sufficient  length  of  time,  vascularization  of  the  inflamed  cornea  will  take 
place,  in  the  course  of  one  or  two  weeks,  by  the  formation  of  new  vessels, 
from  preexisting  sclerotic  vessels  at  the  corneal  border.  The  new  blood- 
vessels grow  in  the  direction  of  the  seat  of  irritation,  occupying  a  triangular 
field,  with  the  apex  directed  toward  the  centre,  the  base  corresponding  to  the 
limbus  cornese.  The  vascular  portion  of  such  a  cornea  is  called  a  pannus. 
In  suppurative  keratitis  the  nuclei  of  the  emigration-corpuscles  undergo 
fragmentation  and  the  corpuscles  are  converted  into  pus-corpuscles;  at  the 
same  time  the  embryonal  cells  exposed  to  the  action  of  the  pus-microbes  fur- 
nish another  histological  source  for  pus  production.  The  fibrous  tissue 
within  the  suppurating  area  necroses,  on  account  of  the  disturbed  nutrition 
and  the  toxic  effect  of  the  pus-microbes  and  their  toxins,  and  an  abscess  re- 
sults. .  Vascularization  of  an  inflamed  cornea  furnishes  one  of  the  most  beau- 
tiful illustrations  of  the  presence  of  protective  resources  in  the  organism, 
which,  when  called  upon  to  meet  different  emergencies,  render  material  aid 
in  the  prevention  or  limitation  of  destructive  processes.  Every  oculist  is 
familiar  with  the  fact  that  extensive  suppurative  keratitis  manifests  no  tend- 
ency to  reparative  action  when  conditions  are  present  that  retard  or  com- 


INFLAMMATION    OF    NON-VASCULAR   TISSUE. 


133 


pletely  prevent  the  formation  of  a  pannus.  As  soon  as  the  process  of  repair 
has  been  completed  the  new  vessels  disappear,  leaving  a  transparent  cornea 
if  the  defect  has  been  within  the  limits  of  the  regenerative  capacity  of  the 
tissues;  in  case  the  loss  of  substance  has  been  too  great  for  complete  restora- 
tion of  structure  and  function,  healing  is  accomplished  by  the  formation  of 
ordinary  cicatricial  tissue,  which  results  in  the  formation  of  a  scar:  a  per- 
manent opacity  of  the  cornea.    In  keratitis  without  suppuration,  or  attended 


Fig.  72.— Artificial  Keratitis.  Kitten.  Silver  Staining.  X  450.  A,  isolated  and  nu- 
cleated cell;  B,  a  group  of  such  still  retaining  something  of  the  shape  of  a  plasma-canal; 
G,  C,  plasma-canals  breaking  into  fragments;  D,  the  fibrous  basis  of  the  lamellae,  or  the 
ground-substance.     (Hamilton.)  > 


by  a  limited  ulceration,  the  cloudiness  of  the  cornea  resulting  from  cell- 
infiltration  and  the  presence  of  embryonal  cells  in  moderate  abundance, 
transparency  is  restored  with  the  removal  of  the  wandering  cells  by  gran- 
ular degeneration  and  absorption,  or  their  return  into  the  circulation,  and 
the  repair  of  the  lesion  by  the  transformation  of  the  embryonal  cells  into 
mature,  perfect,  corneal  tissue. 

Cartilage.  —  Cartilage  is  a  structure  not  only  devoid  of  blood-vessels. 


134  PKINCIPLES    OP    SUKGEEY. 

but  also  of  any  kind  of  vascular  spaces  for  plasma  circulation.  Nutrition 
must  here  take  place  by  intercellular  and  intracellular  diffusion  of  plasma. 
In  its  structure  it  resembles  the  cornea.  On  account  of  the  absence  of  any 
direct  or  indirect  connection  of  cartilage-tissue  with  the  vessels  of  the  peri- 
chondrium, all  regenerative  processes  are  slow  and  imperfect,  and  the  inflam- 
matory lesions,  which  only  occasionally  are  found  here  as  a  primary  affection, 
are  noted  for  their  chronicity.  Artificial  chondritis  was  studied  by  Groodsir 
and  Eedfern.  Certain  parenchymatous  changes  were  noted  at  different  times 
after  cauterization  of  articular  cartilage.  They  consist  essentially  in  the 
enlargement  of  the  cartilage-cells,  with  increase  of  the  nuclei,  or  of  peculiar 
corpuscles  contained  in  them,  or  with  fatty  degeneration  of  their  contents 
and  fading  or  similar  degeneration  of  their  nuclei.  The  hyaline  intercellular 
substance  at  the  same  time  splits  up  and  softens  into  a  gelatinous  and  finely 
molecular  and  dotted  substance.  When  molecular  disintegration  or  ulcera- 
tion of  cartilage  takes  place,  the  enlarged  cartilage-cells  on  the  surface  are 
liberated  and  the  cement-substance  disappears  in  a  similar  manner  after 
having  undergone  liquefaction.  Kliss  stated  that  he  had  recognized,  in 
articular  cartilage  under  the  influence  of  irritants,  certain  fibrous  transforma- 
tions, and  believed  that  he  had  seen,  in  one  case,  changes  taking  place  within 
the  cartilage-cells.  If  articular  cartilage  be  examined  in  the  neighborhood 
of  an  ulcerated  spot,  a  complete  separation  of  the  fibres — the  existence  of 
which  in  its  laminated  structure  was  demonstrated  by  Thin,  by  a  special 
method  of  silver  staining — and  its  reversion  to  ordinary  white  fibrous  tissue 
can  be  readily  made  out. 

Weber  describes  new  vessels  as  not  only  extending  over  the  surface  of 
the  ulcerating  cartilage,  but  afterward  penetrating  its  substance.  In  long- 
standing ulceration  of  cartilage  a  well-marked  pannous  condition  is  usually 
found  present,  which  has  resulted  from  the  development  of  new  blood-ves- 
sels from  the  vessels  of  the  perichondrium,  which  grow  in  the  direction  of 
the  inflammatory  focus  in  the  same  manner  as  in  keratitis.  Defects  of  carti- 
lage caused  by  inflammation,  like  defects  resulting  from  a  trauma,  are  only 
partially  repaired  on  account  of  the  low  vegetative  capacity  of  the  cartilage- 
cells,  and  the  product  of  tissue-proliferation  is  transformed  into  connective 
tissue. 

PHAGOCYTOSIS. 

Until  some  sixty  years  ago  humoral  pathology  was  the  prevailing  one. 
Since  that  time,  through  the  influence  of  the  epoch-making  labor  of  Virchow 
and  his  followers,  the  cellular  pathology  has  been  established. 

It  has  been  known  for  a  long  time  that  absorbable  aseptic  tissues  in 
the  living  body  are  capable  of  removal  by  the  action  of  certain  cells.  The 
absorption  of  aseptic  catgut  ligatures  by  leucocytes  and  embryonal  cells, 


PHAGOCYTOSIS.  135 

which  accumulate  around  it  and,  later,  infiltrate  it,  affords  a  good  illustra- 
tion of  this.  Metschnikoff's  paper  on  phagocytosis  was  published  in  1884, 
three  years  after  Sternberg  had  placed  himself  on  record  in  reference  to  the 
destruction  of  pathogenic  microbes  by  leucocytes.  In  1881  the  latter  author, 
in  a  paper  read  before  the  American  Association  for  the  Advancement  of 
Science,  used  the  following  language: — 

"It  has  occurred  to  me  that  possibly  the  white  corpuscles  may  have  the 
office  of  picking  up  and  digesting  bacterial  organisms  which  by  any  means 
find  their  way  into  the  blood.  The  propensity  exhibited  by  the  leucocytes 
for  picking  up  inorganic  granules  is  well  known,  and  that  they  may  be  able, 
not  only  to  pick  up,  but  to  assimilate  and  so  dispose  of  the  bacteria  which 
come  in  their  way  does  not  seem  to  me  very  improbable,  in  view  of  the  fact 
that  amoebae,  which  resemble  them  so  closely,  feed  upon  bacteria  and  similar 
organisms." 

Metschnikoff  has  introduced  the  term  'phagocytosis  to  designate  a  process 
by  which  leucocytes  and  other  cells  remove  dead  material  and  destroy  or 
digest  pathogenic  microorganisms.  The  cells  which  perform  these  func- 
tions he  calls  phagocytes.  The  leucocytes  are  called  microphagi,  and  the 
fixed  tissue-cells,  which  are  capable  of  performing  the  same  function,  macro- 
phage Pigment-granules,  minute  fragments  of  tissue,  and  microbes  gain 
entrance  into  a  cell,  either  by  the  projections  which  are  thrown  out  by  amoe- 
boid cells  surrounding  and  inclosing  them  (intussusception)  or,  in  the  ab- 
sence of  amoeboid  movements,  by  a  special  property  of  the  cells,  by  which 
they  take  up  into  their  protoplasm  solid  particles  of  various  kinds.  The  cells 
which  are  known  to  possess  phagocytic  properties  are  the  leucocytes,  mu- 
cous corpuscles,  connective-tissue  cells,  endothelia  of  blood-vessels  and 
lymphatic  vessels,  alveolar  epithelium  of  the  hmgs,  and  the  cells  of  the 
spleen,  bone-marrow,  and  lymphatic  glands.  One  of  Metschnikoff's  first 
experiments  consisted  in  introducing  imder  the  skin  of  an  insusceptible 
animal — the  frog — a  fragment  of  tissue  from  the  liver  or  spleen  of  an 
anthracic  animal.  The  implanted  piece,  when  examined  a  couple  of  days 
later,  was  coated  with  a  gelatinous  exudation,  full  of  leucocytes.  These  leu- 
cocytes were  charged  with  bacilli,  which  he  observed  to  be  in  various  stages 
of  degeneration.  If  the  animal  was  kept  at  an  ordinary  temperature  no 
harm  resulted,  but  if  it  was  exposed  at  the  time  and  subsequently  to  a  tem- 
perature of  38°  C.  the  leucocytes,  paralyzed  by  so  high  a  temperature,  failed 
in  their  phagocytic  action,  the  bacilli  multiplied,  and  the  frog  inevitably 
died.  A  much  more  accurate  and  convincing  experiment  was  made,  consist- 
ing in  the  introduction  under  the  skin  of  the  same  animal  a  membranous 
tube — made  of  the  lining  of  a  species  of  large  grass  which  grows  on  the 
banks  of  rivers  (phragmites) — containing  spores  of  bacillus  anthracis.  Soon 
the  little  tube  filled  with  lymph,  but  contained  no  leucocytes,  for  to  them 


136 


PEINCIPLBS    OF    SURGEEY. 


the  membrane  is  impermeable.  A  similar  experiment  was  made  with  another 
tube,  of  which  the  ends  were  left  open  so  that  leucocytes  could  enter.  In  a 
day  or  two  both  tubes  were  examined.  The  contents  of  the  closed  tube 
swarmed  with  virulent  bacilli.  In  the  open  tube  the  spores  had  been  go 
effectually  disposed  of  by  the  leucocytes  that  the  contents  could  be  inoculated 
into  susceptible  animals  without  effect.  Metschnikoff  next  studied  phago- 
cytosis in  the  tail  of  the  tadpole,  and  found  that  the  separation  of  this  organ 
at  the  time  this  animal  is  developed  into  a  frog  is  accomplished  by  leuco- 
cytes. At  the  time  when  the  hind  legs  begin  to  bud  the  leucocytes  migrate 
into  the  tail,  and  at  the  point  where  separation  is  to  take  place  they  attack 
the  tissues,  minute  fragments  of  which  may  be  seen  in  the  interior  of  their 
protoplasm.  In  the  daphnia,  the  common  water-flea,  he  studied  the  destruc- 
tion of  a  fungus — with  which  these  insects  are  prone  to  be  infected — by  the 


Fig.  73. — Phagocytosis.     Struggle  between  Anthrax  Bacillus  and  Leucocyte.     A, 
successful  phagocytosis;    B,  unsuccessful  phagocytosis. 


microphagi.  When  phagocytosis  proved  successful  he  witnessed  the  destruc- 
tion of  the  fungus  in  the  interior  of  leucocytes;  on  the  other  hand,  when  the 
fungi  were  present  in  such  large  numbers  that  the  leucocytes  were  unable 
to  destroy  or  digest  them,  the  daphnia  died.  Next,  he  investigated  phago- 
cytosis in  a  number  of  diseases, — erysipelas,  anthrax,  relapsing  fever,  and 
tuberculosis.  In  erysipelas  the  cocci  are  first  attacked  by  the  leucocytes  fill- 
ing the  lymph-spaces,  and,  later,  by  the  fixed  connective-tissue  cells.  In  the 
path  of  destruction  he  saw  leucocytes  loaded  with  cocci,  the  latter  showing 
various  stages  of  dissolution.  The  connective-tissue  cells  were  also  engaged 
in  the  removal  of  disintegrated  leucocytes.  In  fatal  cases  of  erysipelas  the 
streptococci  multiplied  with  such  great  rapidity  that  the  phagocytes  were 
unable  to  cope  successfully  with  the  disease.  Eibbert  experimented  with  the 
spores  of  aspergillus  and  mucor,  and  the  results  were  such  that  he  claimed 
that  spores  in  the  interior  of  leucocytes,  the  connective  tissue  of  the  liver,  and 


PHAGOCYTOSIS.  137 

the  giant  cells  which  develop  in  the  liver  and  in  the  lungs  are  destroyed,  but 
that  their  destruction  is  not  accomplished  so  much  to  phagocytic  action  of 
the  cells  as  to  the  exclusion  from  them  of  nourishment  for  the  spores,  par- 
ticularly of  oxygen.  Laer  injected  into  the  lungs  through  the  trachea 
cultures  of  the  staphylococcus  in  rabbits,  with  the  result  of  causing  a  catar- 
rhal inflammation.  The  cocci  were  removed  by  leucocytes  and  the  em- 
bryonal epithelia  of  the  alveoli.  During  the  first  week  these  cells  contained 
many  cocci,  but  during  the  second  week  they  disappeared  in  the  cells,  and 
the  animals  recovered. 

Metschnikoff^s  doctrine  of  phagocytosis  has  met  with  violent  opposition 
by  a  number  of  eminent  pathologists,  and  foremost  among  them  we  find 
Baumgarten.  In  a  number  of  publications  this  author  has  taken  a  positive 
and  firm  stand  against  the  claim  that  cells  have  the  power  to  digest  or  destroy 
the  microbes  which  inhabit  their  protoplasm.  Holmfeld,  Bitter,  Prudden, 
and  Nuttal  have  also  arrayed  themselves  against  Metschnikoff.  With  some 
modifications,  Klebs  is  a  believer  in  phagocytosis.  In  a  very  interesting  paper 
on  this  subject  Osier  gives  the  result  of  his  own  observations  on  the  phago- 
cytic action  of  the  cells  lining  the  bronchial  tubes  and  the  alveoli  of  the 
lungs.  He  shows  very  conclusively  how  minute  foreign  particles  are  elim- 
inated by  means  of  the  phagocytic  action  of  the  cells.  In  connection  with 
the  subject  of  inflammation,  the  doctrine  of  phagocytosis  should  be  employed 
in  a  wider  sense  than  was  assigned  to  it  by  Metschnikoff.  In  the  first  place, 
the  accumulation  of  leucocytes  at  the  seat  of  inflammation  must  be  consid- 
ered in  the  light  of  a  mechanical  barrier:  an  attempt  to  protect  the  tissues 
against  infection.  Unfortunately,  in  acute  inflammation,  this  wall  is  usually 
more  apparent  than  real,  as  the  microbes  become  diffused  through  the 
plasma-stream,  and  are  transported  by  the  leucocytes  themselves;  hence  the 
progressive  nature  of  the  process.  The  connective-tissue  proliferation  proves 
more  successful  than  emigration  in  limiting  the  dissemination  of  microor- 
ganisms in  the  tissues,  as  the  new  cells,  so  long  as  they  remain  attached  to 
the  matrix  which  produces  them,  remain  stationary,  and  mechanically  block 
the  avenues  through  which  dissemination  takes  place.  It  is  the  impermea- 
ble wall  of  granulation-tissue  that  surrounds  a  suppurating  depot  which 
finally  limits  suppurative  inflammation.  In  the  next  place,  the  phagocytes 
are  scavengers  which  remove  foreign  dead  particles  from  the  tissues.  Lang- 
hans  was  the  first  to  show  that  extravasated  blood  did  not  simply  disintegrate 
and  disappear,  but  that  the  connective-tissue  elements  were  actively  at  work, 
and  that  many  of  the  colored  corpuscles  disappear  in  their  interior.  Eosen- 
berger  implanted  stained  aseptic  tissue  into  the  abdominal  cavity  of  animals, 
and,  on  examining  the  parts  a  few  weeks  later,  found  that  not  only  had  the 
tissues  been  completely  removed  by  leucocytes,  but  he  was  able  to  follow 
the  course  of  the  leucocytes,  after  they  had  left  the  feeding-ground,  by  col- 


138  PEINCIPLES    OF    SUEGEEY. 

ored  lines^  all  of  which  were  seen  to  radiate  from  the  place  where  the  stained 
tissue  had  been  fixed.  In  different  pathological  conditions  where  tissue- 
proliferation  was  in  process,  Klebs  could  find  positive  evidence  that  wan- 
dering cells  that  had  undergone  fragmentation  had  been  appropriated  by 
the  embryonal  cells  as  food,  as  fragments  of  the  nuclear  chromatin  of  the 
leucocytes  could  be  discovered  in  the  protoplasm  of  the  new  cells.  In  the 
reparative  process  which  follows  the  subsidence  of  inflammation  a  great 
deal  of  cellular  debris  is  to  be.  removed,  and  this  work  is  performed  by  the 
phagocytes,  notably  by  the  fixed  tissue-cells  in  a  state  of  proliferation.  The 
vegetative  capacity  of  the  cells  is  augmented  by  the  reception  into  their 
protoplasm  of  nutritive  material  furnished  them  by  cells  which  have  suc- 
cumbed in  the  struggle.  Metschnikoff  believed  that  the  destruction  of 
microorganisms  in  the  interior  of  phagocytes  was  an  active  process,  and  that 
the  protoplasm  had  a  sort  of  digestive  action  upon  them.  To  prove  the  cor- 
rectness of  this  supposition  he  made  some  experiments  with  the  bacillus  of 
tuberculosis.  He  injected  a  pure  culture  of  the  bacilli  into  the  subcutaneous 
tissue  of  white  rats,  and,  later,  produced  artificially  suppuration  at  the  seat 
of  injection.  Two  months  later  he  found  bacilli  in  the  pus-corpuscles  in  an 
unchanged  condition,  and  without  having  lost  their  power  of  reproduction. 
As  in  other  experiments  he  had  witnessed  the  destruction  and  disappearance 
of  the  same  bacillus  in  living  cells,  he  concluded  that  phagocytosis  is  an 
active  process  which  can  only  take  place  in  a  living  cell,  and  is  suspended 
with  the  death  of  the  cell.  In  mouse-septicgemia  and  in  gonorrhoeal  pus 
many  of  the  leucocytes  are  stuffed  with  microbes,  while  ethers  do  not  con- 
tain a  single  bacterial  cell:  a  condition  which  would  tend  to  prove  that  the 
bacterial  contents  in  each  leucocyte  were  the  offspring  of  a  single  microbe, 
and  could  be  advanced  as  an  argument  against  the  phagocytic  action  of  the 
leucocytes.  On  the  other  hand,  the  bacilli  in  the  interior  of  leucocytes  in 
anthracic  animals  present  evidences  of  degeneration,  which  speaks  in  favor 
of  the  phagocytic  theory. 

In  1890  Metschnikoff  summarized,  at  the  close  of  a  lecture  on  this  sub- 
ject, his  convictions  as  follows:  "It  is  not  possible  at  the  present  time  to 
state  fully  and  accurately  all  those  influences  which  are  associated  in  aiding 
phagocytic  action,  but  already  we  have  the  right  to  maintain  that,  in  the 
property  of  its  (the  blood)  amoeboid  cells  to  include  and  to  destroy  microor- 
ganisms, the  animal  body  possesses  a  formidable  means  of  resistance  and 
defense  against  these  infectious  agents." 

There  are  a  few  at  this  time  who  regard  the  destruction  and  disappear- 
ance of  microbes  in  phagocytes  as  an  act  of  digestion.  If,  however,  microbes 
in  the  interior  of  phagocytes  are  rendered  harmless  or  disintegrate  and  dis- 
appear, this  fact  is  an  important  one,  and  it  is  immaterial  in  what  way  this 
result  is  obtained,  whether  the  microbes  are  digested  by  the  protoplasm,  or 


IMMUNITY.  139 

whether  some  chemical  substance  in  the  cell-body  exerts  an  inhibitory  effect 
upon  them,  or,  finally,  whether  for  want  of  a  proper  nutrient  material  they 
are  starved,  as  it  were.  The  results  of  experimental  research  have  furnished 
positive  evidence  that  infective  processes  terminate  most  favorably  where 
the  conditions  described  as  phagocytosis  are  accomplished  most  satisfactorily. 
In  all  acute  inflammatory  processes  the  number  of  white  corpuscles  in  the 
blood  is  invariably  increased,  and  they  take  an  active  part  in  destroying  the 
microbic  cause  of  the  original  affection. 

When  the  struggle  between  a  microbe  and  a  phagocyte  turns  out  in 
favor  of  the  latter,  the  microbe  does  not  multiply  in  the  protoplasm,  or  ceases 
to  do  so  before  the  protoplasm  is  destroyed,  and,  as  the  microbe  cannot  leave 
without  dissolution  of  the  cell,  it  remains  within  its  narrow  confinement  and 
is  destroyed,  either  by  some  as  yet  unknown  chemical  substance  or  dies  from 
starvation;  in  either  event  the  vitality  of  the  cell  is  not  impaired,  and  the 
microbe  disintegrates  and  disappears.  (Fig.  73,  A.)  If  the  conditions  for 
the  growth  and  development  of  the  microbe  in  the  protoplasm  of  the  cell 
are  more  favorable,  intracellular  multiplication  of  the  microbe  takes  place, 
the  toxins  which  are  eliminated  produce  coagulation-necrosis  in  the  pro- 
toplasm, the  cell  disintegrates,  and  the  intracellular  culture  is  liberated  in  an 
active  condition.  (Fig.  73,  B.)  In  cases  of  unsuccessful  warfare  of  the 
phagocytes  against  invading  microorganisms,  the  mechanical  obstruction 
composed  of  emigration  corpuscles  and  embryonal  cells  is  broken  down,  and 
the  rapid  increase  of  microorganisms  at  the  seat  of  inflammation  gives  rise 
to  extensive  local  and  often  general  infection.  From  a  practical  stand-point 
it  can  be  said  that  all  therapeutic  measures  which  influence  favorably  the 
process  of  phagocytosis,  in  the  broadest  meaning  of  this  word,  are  calculated 
to  exert  a  potent  influence  in  arresting  or  limiting  infective  processes. 

IMMUNITY. 

In  opposition  to  Metschnikoff,  Buchner,  Denys,  and  many  followers 
believe  that  the  destruction  of  bacteria  within  the  body  is  effected  by  the 
bacteria-destroying  elements  which  are  always  present  in  the  blood  outside 
of  the  body.  These  differences  of  opinion  are  being  modified  by  the  results 
of  clinical  observation  and  experimental  research.  Metschnikoff  himself  is 
now  of  the  opinion  that  the  fluids  of  the  body  contain  also  some  bacteria- 
destroying  properties,  but  he  maintains  that  they  are  derived  from  the  liv- 
ing broken-down  leucocytes;  and  Buchner  now  takes  the  ground  that  the 
alexins  are  derived  from  the  living  leucocytes  which  secrete  them.  Meltzer, 
of  New  York,  advances  the  idea  that  one  of  the  resisting  powers  to  infectious 
diseases  is  plasmolysis,  as  he  believes  that  the  organisms  remain  in  the  hy- 
pertonic animal  fluid  for  some  time,  the  state  of  plasmolysis  becomes  per- 


140  PRINCIPLES    OF    SUEGEEY. 

manent,  and  the  bacteria  succumb  steadily  either  to  the  effects  of  the  plas- 
molysis  itself  or  some  insignificant  accidental  injury.  By  the  observations 
of  Adami  and  other  investigators  we  might  consider  it  as  an  established  fact 
that  the  interior  of  the  body  is  regularly  invaded  by  bacteria^,  which,  how- 
ever, do  not  localize,  but  are  sornewhat  later  destroyed.  The  successful  em- 
ployment of  some  of  the  antitoxins  in  the  prevention  and  cure  of  certain 
infectious  diseases  is  conclusive  proof  of  the  existence  of  other  agencies 
besides  phagocytosis  in  counteracting  the  effect  of  pathogenic  microbes.  It 
appears  to  be  an  established  fact  that  the  effective  antitoxins  combine  with 
the  toxins  and  form  harmless  compounds.  The  view  that  antitoxins  act 
indirectly  by  stimulating  or  immunizing  living  cells  seems  to  be  losing 
ground.  The  combination  which  the  antitoxins  enter  into  with  their  re- 
spective toxins  is  not  exactly  comparable  to  those  of  an  acid  with  an  alkali, 
because  it  is  a  much  slower  one,  but  it  is  one  which,  as  suggested  by  Ehrlich, 
resembles  the  formation  of  a  double  salt.  In  reference  to  the  duration  of 
immunity,  Eansom's  experiments  made  in  Ehrlich's  laboratory  show  that  a 
kindred  serum  is  longest  retained,  but  that  alien  serums  are  not  all  dis- 
posed of  with  the  same  rapidity.  Behring  speaks  of  active  and  passive  im- 
munization, but  not  of  active  (treatment  with  toxin)  and  passive  immunity 
(treatment  with  antitoxin),  since  in  whichever  of  the  two  ways  it  is  pro- 
duced the  resulting  hfematogenic  immunity  is  the  essential  fact.  Horses 
made  immune  with  horse-serum  retain  their  immunity  scarcely  less  long 
than  is  the  case  with  animals  made  isopathically  immune. 

CHEONIC    INFLAMMATION. 

Chronic  inflammation  differs  from  the  acute  form  only  in  degree.  The 
vascular  changes  which  have  been  described  come  on  slowly,  and  are  never 
so  marked  as  in  acute  inflammation;  and  on  this  account  the  emigration 
of  blood-corpuscles  occurs  slowly,  and  in  some  instances  it  is  entirely  want- 
ing. The  inflammatory  product  is  largely,  and  in  some  cases  exclusively, 
composed  of  embryonal  cells  derived  from  fixed  tissue-cells.  The  noxce 
which  excite  chronic  inflammation  are  such  that  exert  their  deleterious  effect 
more  on  the  tissue-cells  directly  than  the  capillary  vessels.  Their  primary 
action  on  the  tissues  consists  in  increasing  the  vegetative  capacity  of  the 
cells;  hence,  mature  cells  are  transformed  into  embryonal  or  granulation 
tissue  and  remain  in  this  condition  as  long  as  the  noxce  exist,  and  retain  their 
pathogenic  qualities  or  otherwise  until  the  new  cells  undergo  retrograde 
metamorphosis.  If  in  a  chronic  inflammation  degeneration  of  the  embryonal 
cells  has  not  taken  place,  and  the  primary  cause  has  ceased  to  act,  the  new 
tissue  is  either  removed  by  absorption  or  is  converted  into  mature  tissue,  in 
which    event   the   inflammation    has   resulted   in    hyperplasia.      Syphilitic 


CliRONIC    INFLAMMATION.  141 

gimimata,  which  are  composed  almost  exclusively  of  embryonal  tissue^  dis- 
appear promptly  under  a  vigorous  antisyphilitic  treatment;  because  by  such 
treatment  the  microorganisms  which  have  caused  the  lesion  are  either  de- 
stroyed or  at  least  have  been  deprived,  for  the  time  being,  of  their  pathogenic 
properties. 

Chronic  inflammation  is  represented  by  that  large  class  of  affections 
which  are  included  under  the  name  granulomata.  These  swellings,  irre- 
spective of  their  primary  microbic  cause,  are  composed  of  what  is  known 
as  granulation-tissue.  Some  pathologists  have  been  inclined  to  classify  them 
with  tumors  because  their  development  is  seldom  attended  by  well-marked 
symptoms  of  inflammation,  and  in  their  methods  of  regional  and  general 
dissemination  they  bear  a  close  resemblance  to  the  malignant  tumors.  Their 
obstinacy  to  successful  treatment  does  not  depend  upon  any  malignant 
qualities  of  the  tissues  of  which  they  axe  composed,  but  upon  the  difficulty 
of  eliminating  or  rendering  inert  the  primary  cause  by  internal  medication 
or  operative  procedures. 

All  granulomata  are  inflammatory  m  their  origin,  and  under  the  micro- 
scope present  all  the  characteristic  appearances  of  inflamm,ation:  Histologic- 
ally they  are  composed  of  embryonal  cells  which  correspond  to  the  type  of 
the  tissues  in  which  or  from  which  they  have  developed.  In  a  tubercular 
nodule  we  find  giant  cells,  epithelioid  cells,  the  ordinary  granulation-cell, 
and  leucocytes.  Actinomycotic  swellings  are  composed  almost  exclusively 
of  embryonal  connective  tissue.  Many  of  the  granulomata  contain  Ehrlich's 
plasma-cells  (Mastzellen),  of  unknown  origin,  composed  of  a  finely-granular 
mass  around  a  vesicular  nucleus.  On  staining  with  aniline  colors,  the 
nucleus  remains  unchanged,  while  the  granules  are  deeply  stained.  The 
cells  are  about  the  size  of  a  leucocyte,  either  spherical  or  somewhat  elongated 
in  shape.  In  some  cases  the  outer  portion  of  the  inflammatory  product, 
being  sufficiently  remote  from  the  infected  area,  is  converted  into  a  Arm 
connective-tissue  capsule,  which  limits  the  extension  of  infection,  while  its 
interior,  from  the  presence  of  the  specific  microorganisms,  but  probably  more 
on  account  of  inadequate  blood-supply,  the  tissues  undergo  rajDid  retrograde 
degenerative  changes. 

Secondary  infection  in  a  granuloma,  either  through  the  circulation  or, 
what  is  more  common,  from  without,  through  some  minute  infection-atrium, 
is  a  not  uncommon  occurrence.  Secondary  infection  almost  always  means 
localization  of  pus-microbes  in  the  granulation-tissue  and  a  breaking  down 
of  the  latter  into  pus-corpuscles.  The  serious  consequences  Avhich  follow 
suppurative  inflammation  of  a  gumma  developing  after  incision  made  upon 
a  wrong  diagnosis  are  well  known.  Infection  of  a  large  tubercular  depot 
with  pus-microbes  after  incision  without  proper  antiseptic  precautions,  or 
after  spontaneous  evacuation,  is  followed  by  destruction  of  the  remaining 


142  PEINCIPLES    OF    SURGERY. 

granulations,  profuse  suppuration,  and  not  infrequently  by  death  from  sep- 
sis. Actinomycosis  gives  rise  to  a  large  granuloma  without  any  tendeucy  to 
suppuration  until  infection  takes  place  with  pus-microbes,  when  the  .granula- 
tions melt  away  rapidly,  leaving  a  deep  ulcer  with  ragged,  undermined  mar- 
gins, and  a  speedy  extension  of  the  combined  infective  processes,  following 
the  connective  tissue  in  their  course. 

The  secondary  infection,  however,  may  prove  beneficial  and  become  the 
means  of  complete  elimination  of  the  inflammatory  product  and  microor- 
ganisms of  the  primary  infection.  In  this  way  a  localized  tubercular  lesion 
is  sometimes  cured  spontaneously  by  suppuration.  A  suppurative  inflam- 
mation of  a  tubercular  gland  of  the  neck  is  often  followed  by  complete  re- 
moval of  the  bacilli-containing  tissues  and  a  permanent  cure.  All  chronic 
inflammatory  processes  are  attended  by  recurring  attacks  of  acute  exacer- 
bations. If  during  these  attacks  in  the  periphery  of  the  chronically-inflamed 
area  a  more  active  cell-proliferation  is  initiated,  the  conditions  for  a  more 
successful  phagocytosis  are  improved  and  the  acute  attack  has  proved  a 
curative  measure. 

The  surgeon  often  resorts  to  measures  which  result  in  the  transforma- 
tion of  a  chronic  into  an  acute  inflammation,  in  imitation  of  Nature's  efforts 
in  the  same  direction.  In  illustration  of  this,  I  will  only  mention  ignipunct- 
ure.  The  fenestration  of  a  chronic  inflammatory  swelling  under  strict  anti- 
septic precautions  has  proved  a  valuable  therapeutic  resource  by  securing 
drainage,  but  more  especially  because  around  each  tubular  eschar  made  with 
the  needle-point  of  a  Paquelin  cautery  a  zone  of  active  tissue-proliferation  is 
created,  and  the  new  tissue,  by  undergoing  transformation  into  cicatricial 
tissue,  serves  a  useful  purpose  in  starving  out  microbes  that  have  escaped  the 
cautery.  Another  instructive  instance  of  the  benefits  which  accrue  from  the 
substitution  of  an  acute  for  a  chronic  inflammation  is  found  in  the  use  of 
jequirity  in  ophthalmic  practice.  The  powdered  bean  or  some  other  prep- 
aration of  this  drug,  when  brought  in  contact  with  the  conjunctiva,  pro- 
duces a  violent  inflammation  which  has  frequently  proved  a  curative  measure 
in  the  treatment  of  trachoma  and  some  forms  of  pannus  of  the  cornea. 

One  of  the  ways  in  which  an  acute  inflammation  acts  beneficially  in 
promoting  the  process  of  resolution  in  tissues  the  seat  of  a  chronic  inflam- 
mation is  by  its  stimulating  action  on  the  capillary  vessels.  The  active 
hypersemia  may  become  the  means  of  clearing  partially-obstructed  capillary 
vessels  of  implanted  colorless  corpuscles,  and  thus  remove  from  the  weak- 
ened tissues  not  only  the  mechanical  causes  which  have  maintained  the 
chronic  congestion,  but  also  the  intravascular  cause  of  the  inflammation: 
the  microbes.  When  the  infected  corpuscles  reach  the  general  circulation 
there  is  a  chance  for  more  effective  phagocytosis  and  elimination  of  the 
microbes  through  one  or  more  of  the  excretory  organs. 


SYMPTOMS    AND    DIAGNOSIS    OF    INFLAMMATION.  143 

SYMPTOMS    AND    DIAGNOSIS    OF    INFLAMMATION. 

For  practical  purposes^,  inflammation  may  be  divided  into  acute,  sub- 
acute, and  chronic,  according  to  the  intensity  of  symptoms  and  the  time 
required  to  reach  one  of  its  terminations.  The  nature  of  the  primary  cause 
determines  the  course  and  nature  of  the  inflammation.  The  microbes  of 
suppuration,  erysipelas,  anthrax,  glanders,  tetanus,  and  gonorrhoea  cause 
acute  affections,  while  the  microorganisms  of  tuberculosis,  lepra,  and  actino- 
mycosis cause  lesions  which  are  noted  for  their  chronicity.  Acute  inflamma- 
tion may  become  subacute  and  finally  chronic,  as  in  suppurative  osteomye- 
litis, where,  if  the  disease  is  multiple,  in  the  first  bone  affected  it  pursues  a 
very  acute  course;  while  often  in  the  successive  bones  attacked  it  is  less 
intense,  and  not  infrequently  in  the  last  bone  involved  it  appears  as  a  chronic 
affection.  A  chronic  inflammation  may  be  followed  by  a  subacute  or  acute 
attack,  as  is  frequently  observed  in  tuberculosis  complicated  by  secondary 
infection  with  pus-microbes.  In  acute  inflammation  the  local  and  general 
symptoms  are  so  well  marked  that  no  difiiculties  are  in  the  way  of  recog- 
nizing its  existence,  and  it  only  remains  to  decide  upon  its  character.  The 
fever  which  attends  the  inflammation  is  only  a  symptom,  and  indicates  the 
introduction  into  the  general  circulation  of  phlogistic  substances  from  the 
products  of  exudation  or  the  fixed  tissue-cells  which  have  undergone  patho- 
logical changes.  Microbes  that  cause  acute  inflammation  differ  greatly  as 
to  the  amount  or  intensity  of  action  of  the  phlogistic  substances  which  they 
produce  in  the  inflamed  tissues  affected;  also  exert  an  important  influence 
in  modifying  the  febrile  disturbance.  Suppuration  caused  by  the  micro- 
coccus pyogenes  tenuis  is  not  attended  by  so  high  a  temperature  as  when 
produced  by  the  staphylococcus  or  streptococcus.  The  rise  in  temperature 
which  accompanies  inflammation  is  due  either  to  the  introduction  into  the 
circulation  of  fibrin-ferment  resulting  from  the  destruction  of  leucocytes  or 
the  production  of  toxins  by  the  specific  action  of  microbes  on  the  tissues, 
which  act  as  phlogistic  substances  when  introduced  into  the  general  circula- 
tion: a  fact  which  has  been  abundantly  demonstrated  by  clinical  observation 
and  experimental  research.  As  soon  as  the  causes  which  have  produced  the 
rise  in  temperature  in  inflammation  have  been  rendered  inert  by  phagocyto- 
sis, or  have  been  eliminated  with  the  removal  of  the  inflammatory  product, 
the  fever  subsides.  The  general  disturbances,  such  as  headache,  vomiting, 
loss  of  appetite,  thirst,  and  the  ever-present  feeling  of  lassitude  which  attends 
acute  inflammation  of  all  kinds,  are  caused  by  the  fever  and  the  presence 
of  toxic  substances  in  the  blood.  The  symptoms  of  inflammation,  which 
have  been  described  at  length,  must  be  studied  separately  and  conjointly 
in  each  form  of  inflammation,  and  their  individual  and  mutual  significance 
carefully  estimated.    A  local  rise  in  temperature  is  of  more  diagnostic  value 


144  PKINCIPLES    OF    SUEGEEY. 

in  ascertaining  the  existence  of  inflammation  than  fever,  as  the  latter  can 
be  caused  by  the  absorption  of  fibrin-ferment  from  any  causes  which  destroy 
the  colorless  blood-corpuscles  and  the  absorption  of  the  products  of  tissue- 
disintegration  in  malignant  tumors;  while  a  permanent  increase  of  the  tem- 
perature at  the  seat  of  the  disease  denotes  almost  infallibly  the  existence  of 
inflammation.  In  reference  to  the  extension  of  the  inflammatory  process, 
it  can  be  said  that  this  will  be  influenced  by  the  anatomical  structure  of  the 
part  involved  and  the  manner  of  diffusion  of  the  microbe  which  causes  the 
inflammation.  If  a  mucous  or  serou.s  surface  is  affected,  infection  is  prone 
to  spread  rapidly  by  continuity  of  tissue"  and  the  mechanical  dissemination 
of  the  microbes  on  the  surface  in  the  mucous  secretion,  and  by  the  move- 
ments of  one  serous  surface  upon  the  other.  In  erysipelas  the  inflammation 
spreads  rapidly,  as  the  microbe  is  diffused  through  the  lymphatics  and  con- 
nective-tissue spaces.  In  phlegmonous  inflammation  the  pus-microbes  find 
no  mechanical  barriers,  and  are  rapidly  distributed  over  a  larger  area  through 
the  connective-tissue  spaces.  The  same  manner  of  diffusion  is  observed  in 
anthrax  if  the  bacillus  finds  ingress  into  a  part  supplied  with  an  abundance 
of  loose  cellular  tissue,  while  the  disease  remains  circumscribed  and  presents 
itself  in  an  indurated  form  if  it  is  located  in  tissues  which  do  not  present 
such  favorable  anatomical  conditions  for  extension  of  the  local  invasion. 
The  nature  of  the  inflammatory  product  always  answers  to  the  specific 
action  of  the  microbe  in  the  tissues  which  caused  the  inflammation.  Thus, 
an  inflammation  caused  by  pus-microbes  will  result  in  the  formation  of  pus; 
while  the  microbes  which  produce  chronic  inflammation,  as  a  rule,  only  con- 
vert the  preexisting  mature  into  embryonal  tissue.  The  microbes  which 
have  a  short  existence  in  the  tissues  may  give  rise  only  to  intense  hyper- 
semia  and  a  moderate  emigration  of  the  colored  blood-corpuscles,  as,  for 
instance,  the  streptococcus  of  erysipelas.  The  genuine,  uncomplicated  ery- 
sipelatous inflammation  is  of  such  short  duration  that  perfect  restoration 
of  the  parts  is  accomplished  in  a  few  days. 

PEOGNOSIS. 

The  most  favorable  termination  of  inflammation  is  resolution,  with 
restitutio  ad  integrum  of  structure  and  function  of  the  tissues  which  were 
the  seat  of  the  inflammatory  process.  Eesolution  is  only  possible  if  the  emi- 
gration of  blood-corpuscles  is  moderate  in  quantity  and  none  of  the  cellular 
elements  of  the  exudate  are  transformed  into  pus-corpuscles.  If  exudation 
take  place  rapidly,  the  connective-tissue  spaces  are  completely  blocked 
with  the  emigration-corpuscles  and  the  products  of  coagulation-necrosis, 
which  seriously  impairs  or  completely  arrests  plasma-circulation,  and,  by 
pressure  upon  the  blood-vessels,  may  interfere  with  the  capillary  circulation 
to  such  an  extent  as  to  cause  necrosis.     Eesolution,  as  has  been  previously 


PROGNOSIS.  145 

stated,  signifies  that,  after  subsidence  of  tlie  symptoms  of  inflammation,  the 
part  is  left  in  a  condition  capable  of  removing  the  inflammatory  product  and 
of  repairing  the  damage  done.    Many  of  the  leucocytes  which  have  retained 
their  vitality  immigrate  back  into  the  general  circulation  either  through  the 
walls  of  capillaries  or,  what  is  more  frequent,  through  the  lymphatic  system. 
The  remaining  leucocytes  and  colored  corpuscles  undergo  degeneration  and 
are  removed  by  absorption.    Fibrin  which  has  formed  in  the  tissues  is  trans- 
formed into  a  granular  mass  and  is  removed  in  a  similar  manner.    Embryonal 
cells  which  have  become  detached,  or  have  been  damaged  by  the  inflamma- 
tion, are  also  removed  by  absorption  after  they  have  undergone  granular 
degeneration.     The  transudation  is  removed  by  absorption  as  soon  as  capil- 
lary circulation  is  restored  and  the  connective-tissue  spaces  have  been  cleared 
of  their  cellular  contents.     The  capillary  wall  is  repaired,  and  any  tissue- 
defects  are  restored  by  proliferation  of  the  fixed  tissue-cells.     The  inflam- 
matory exudate  may  prove  a  source  of  danger  when,  by  its  mechanical  press- 
ure, it  interferes  with  the  function  of  important  organs,  as  the  brain,  heart, 
or  lungs.     A  moderate  transudation  within  the  skull  from  inflammation 
of  any  of  the  meninges  can  produce  death  from  compression  of  the  brain; 
a  pericardial  effusion,  when  sufficient  in  amount  to  interfere  mechanically 
with  the  action  of  the  heart,  causes  death  by  syncope;  and  a  copious  effusion 
into  the  pleural  cavity,  especially  if  it  come  on  rapidly,  may  impair  respira- 
tion to  such  an  extent  as  to  result  in  death  from  apnoea.    A  slight  croupous 
exudation  upon  the  vocal  cords  or  CBdema  about  the  entrance  to  the  larynx 
destroys  life  by  preventing,  in  a  purely  me-chanical  way,  the  entrance  into 
the  lungs  of  an  adequate  quantity  of  air.    Inflammation  is  greatly  modified 
by  the  age  and  general  condition  of  the  patient.     Infants  and  persons  ad- 
vanced in  years  possess  little  power  of  resistance,  and,  when  attacked  by  in- 
flammation, the  disease  is  prone  to  become  diffuse  and  lead  to  serious  patho- 
logical changes.    The  same  can  be  said  of  persons  who  have  been  debilitated 
by  antecedent  diseases  or  intemperate  habits.     The  greatest  danger  in  the 
different  forms  of  inflammation,  as  far  as  life  is  concerned,  consists  in  the 
introduction  into  the  general  circulation  of  septic  material  produced  in  the 
inflamed  part  by  the  action  of  microbes  on  the  tissues.    This  general  infec- 
tion, occurring  in  the  course  of  a  localized  inflammation,  appears  either  as  a 
symptomatic  fever,  which  disappears  with  the  subsidence  of  the  local  process, 
or  as  a  progressive  septicaemia,  pyaemia,  or  septico-pyaemia.     The  latter  dis- 
eases will  be  considered  in  separate  chapters.    Tubercular  affections  are  al- 
ways attended  by  the  danger  incident  to  extension  of  the  process  to  other 
organs  by  dissemination  of  bacilli  through  the  lymphatic  channels  or  blood- 
vessels.    Chronic  suppuration  finally  causes  amyloid  degeneration  of  im- 
portant organs,  and  death  ensues  from  this  cause.    In  summing  up  what  has 
been  said  under  this  head,  it  is  evident  that  the  prognosis  rests  mainly  upon 


146  PRINCIPLES    OF    SUEGERY. 

the  intrinsic  pathogenic  qualities  of  the  microbe  which  has  caused  tlie  in- 
flammation; the  anatomical  structure,  location,  and  physiological  impor- 
tance of  the  part  or  organ  inflamed;  the  general  condition  of  the  patient, 
and  the  accessibility  to  and  feasibility  of  treating  the  disease  by  direct  radical 
surgical  intervention. 

TREATMENT. 

As  inflammation  per  se  is  no  disease,  but  an  effort  on  the  part  of  the 
organism  and  the  tissues  affected  to  eliminate  or  render  harmless  the  pri- 
mary cause,  the  treatment  must  be,  in  each  individual  case,  purely  symptom- 
atic. A  proper  appreciation  of  the  nature  and  tendencies  of  inflammation 
is  an  essential  prerequisite  to  rational  treatment.  In  surgery  the  prophy- 
lactic treatment  of  inflammation  is  the  most  important  and  satisfactory. 
The  prevention  of  inflammation  in  accidental  and  operation  wounds  by 
strict  antiseptic  and  aseptic  precautions  has  made  modern  surgery  what  it  is. 
The  surgeon  has  it  now  in  his  power,  bj  resorting  to  antiseptic  measures,  to 
prevent  the  innumerable  and  formerl}^  too  often  fatal  wound  complications. 
Lister  has  inaugurated  a  new  era  in  surger}',  and  his  work,  as  well  as  that  of 
his  early  enthusiastic  followers,  has  been  the  means  of  saving  annually  thou- 
sands of  lives.  The  mortality  of  even  the  most  desperate  operations,  where 
the  antiseptic  or  aseptic  treatment  can  be  followed  to  perfection,  has  been  so 
much  reduced  that  operative  surgery  has  received  a  new  impetus,  and  opera- 
tions are  devised  and  put  in  practice  almost  daily  which  formerly  would  have 
been  looked  upon  as  a  freak  of  imagination  or  the  outcome  of  a  diseased 
brain.  The  prophylactic  treatment  of  inflammation  in  dealing  with  wounds, 
or  other  avenues  through  Avhich  infection  can  take  place,  consists  in  securing 
for  the  place  deprived  of  the  effective  protection  against  the  entrance  of 
pathogenic  microorganisms — the  intact  skin  or  mucous  membrane — an  asep- 
tic condition  by  antiseptic  measures,  and  to  bring  in  contact  with  it  only 
things  that  have  been  thoroughly  sterilized. 

In  inflammation  without  an  external  tangible  infection-atrium  we  must 
take  it  for  granted  that  microbes  have  entered  the  circulation  through  slight 
defects  the  existence  of  which,  perhaps,  the  patient  does  not  remember,  and 
which  have  left  no  appreciable  marks  of  their  former  existence,  or  infection 
has  taken  place  through  some  of  the  appendages  of  the  skin  or  through  a 
mucous  membrane,  with  localization  of  the  microbes  in  a  part  or  organ  pre- 
viously prepared  for  their  reception  and  growth;  that  is,  in  a  location  pre- 
senting a  locus  minoris  resistentice. 

Eecognizing  the  fact  that  inflammation,  wherever  it  occurs,  is  produced 
by  the  action  upon  the  vessel-wall  and  the  tissues  outside  of  it  of  specific 
microorganisms,  it  would  appear  that  the  most  rational  indication,  for  treat- 
ment would  be  to  resort  to  such  means  as  would  destrov  the  microbes  in  the 


TREATilEXT. 


147 


tissues  as  soon  as  tlieir  presence  is  manifested  by  their  action.  This  wonld 
impl}'  the  saturation  of  the  inflamed  tissues  with  germicidal  solutions,  which 
from  laborator}^  exjDeriments  are  known  to  be  effectiye  in  destroying,  or  at 
least  inhibiting  the  growth  of,  such  microbes;  hence,  it  has  been  advised  to 
resort  to 

Parenchymatous  Injections. — This  method  of  treatment  was  strongly 
advised  and  extensively  practiced  by  Hueter  long  before  the  direct  relation- 
ship between  certain  microbes  and  definite  forms  of  inflammation  had  been 
demonstrated.    Hueter  claimed  that  everv  inflammation  was  caused  bv  cer- 


Fig.  74. — Hueter's  Infusor. 


tain  7ioxce  introduced  from  without,  and  which  he  aimed  to  destroy  by  satu- 
rating the  inflamed  tissues  with  an  antiseptic  solution.  His  favorite  remedy 
was  a  3-  to  5-per-cent.  solution  of  carbolic  acid.  The  instrument  which  he 
used  was  an  ordinary  Pravaz  syringe,  with  a  long  needle  provided  with  a 
number  of  small  lateral  openings.  In  adults  he  injected  as  much  as  10 
grammes  at  a  time  of  a  3-per-cent.  solution.  In  using  this  method  in  the 
treatment  of  large,  granulating,  tubercular  foci  he  employed  what  he  termed 
an  inf-uso)\  composed  of  a  graduated  glass  cylinder,  joined  with  the  needle 
by  means  of  a  rubber  tube.  By  this  method  of  injection  the  fluid  diffused 
itself  through  the  soft,  crranular  mass  by  its  own  weight.    In  the  treatment 


148  PRINCIPLES    OF    SURGERY. 

of  tubercular  lesions  Hueter  claimed  for  the  parenchymatous  injections  of 
ca'rbolic  acid  great  curative  powers.  Eational  as  this  method  of  treatment 
appears,  it  has  not  yielded  the  results  that  were  anticipated.  The  living  tis- 
sues cannot  be  compared  with  a  test-tube.  Nitrate  of  silver,  iodine,  perman- 
ganate of  potassa,  corrosive  sublimate,  alcohol,  and  other  potent  germicidal 
agents  have  been  used  since,  but  the  results,  on  the  whole,  have  been  any- 
thing but  satisfactory.  If  this  method  of  treatment  is  to  be  successful  in  the 
treatment  of  acute  inflammation,  it  must  be  instituted  at  an  early  stage,  at  a 
time  when  only  a  limited  area  of  tissue  has  been  infected,  as,  under  such  cir- 
cumstances, if  the  area  of  infection  could  be  accurately  outlined,  it  would  be 
possible  to  saturate  the  tissues  with  an  antiseptic  solution  without  running 
the  risk  of  killing  the  patient  by  administering  a  toxic  dose  of  the  drug  em- 
ployed, which  might  be  the  case  if  a  larger  area  were  treated  in  a  similar 
manner.  If  we  remember  that  the  microbes  are  diffused  throughout  the 
entire  exudation  and  constitute  the  most  important  element  of  the  inflam- 
matory product,  it  is  easy  to  understand  that  sterilization  of  the  inflamed 
tissues  by  means  of  parenchymatous  injections  is  not  an  easy  task,  and  we 
are  then  in  a  position  to  realize  why  this  method  of  treatment  has  not  proved 
more  uniformly  successful.  Most  of  the  germicidal  agents  heretofore  em- 
ployed in  this  manner,  when  brought  in  contact  with  the  tissues,  form  com- 
pounds which  prevent  further  diffusion,  and  therefore  each  needle-puncture 
sterilizes  only  a  very  small  portion  of  the  inflamed  district.  It  is  possible 
that  in  the  future  non-toxic,  but  at  the  same  time  effective  germicidal,  sub- 
stances will  be  discovered  which  can  be  used  in  larger  quantities,  and  in  this 
event  the  treatment  of  inflammation  by  parenchymatous  injections  will  have 
a  wide  range  of  application,  and  will  be  practiced  with  better  success.  At 
present  this  method  has  a  limited  field  of  usefulness  in  the  treatment  of 
the  various  forms  of  inflammation.  Under  no  circumstances  should  the 
amount  of  the  drug  used  exceed  the  dose  which  it  would  be  safe  to  admin- 
ister internally,  and  the  danger  of  a  poisonous  dose  should  be  remembered 
in  repeating  the  injection.  An  ordinary  hypodermic  syringe  with  a  long 
needle  can  be  used  in  making  the  injection.  That  the  needle  and  syringe 
should  be  perfectly  aseptic  is  to  be  imderstood  as  a  matter  of  course,  as  un- 
clean instruments  have  often  been  the  means  of  conveying  a  fatal  disease. 
Multiple  punctures  are  to  be  preferred,  as  in  this  manner,  by  using  the  same 
amount  of  fluid,  more  tissue  can  be  saturated  than  by  a  single  puncture. 
Before  making  the  punctures  the  surface  must  be  disinfected.  The  object 
should  be  to  bring  the  antiseptic  solution  in  contact  with  as  much  of  the 
infected  tissues  as  possible,  and  if  the  disease  manifests  a  tendency  to  spread 
it  is  advisable  to  go  beyond  the  zone  of  infection,  as,  for  instance,  in  cases 
of  erysipelas  and  anthrax.  A  5-per-cent.  solution  of  carbolic  acid  is  prefer- 
able to  all  other  antiseptics  in  the  treatment  of  acute  inflammatory  affections 


TEEATMENT.  149 

by  this  method.  Many  accessible  tubercular  affections  are  greatly  benefited 
by  parenchymatous  injections  of  carbolic  acid.  Eecently,  intraarticular  and 
parenchymatous  injections  of  iodoform  have  been  strongly  recommended  in 
the  treatment  of  articular  and  other  forms  of  surgical  tuberculosis. 

Antiphlogistic  Treatment. — An  erroneous  conception  of  the  nature  and 
tendencies  of  inflammation  has  for  centuries  induced  the  ablest  teachers 
and  practitioners  to  advocate  and  practice  what  they  termed  the  anti- 
phlogistic treatment  of  inflammation.  This  included  blood-letting,  cupping, 
leeching,  and  the  internal  use  of  emetics  and  cathartics.  It  was  urged  that 
as  inflammation  is  attended  by  an  increase  of  heat,  swelling,  and  redness, 
such  remedies  should  be  employed  as  will  reduce  arterial  tension.  Venesec- 
tion is  now  seldom,  if  ever,  resorted  to  in  the  treatment  of  any  form  of  in- 
flammation. An  unimpaired  vis  a  tergo  is  one  of  the  best  means  to  prevent 
stasis  within  the  inflamed  capillaries,  and  practical  experience  has  shown 
that  all  remedies  and  agents  which  diminish  the  intraarterial  tension  only 
diminish  the  prospects  for  a  favorable  termination  of  the  inflammation. 
Cohnheim  showed  experimentally  that  the  threatened  stasis  in  the  exposed 
mesentery  of  the  frog  was  avoided  by  injecting  into  one  of  the  veins  1 
centimetre  of  a  6-per-cent.  solution  of  sodic  chloride.  If,  under  similar  con- 
ditions, a  considerable  quantity  of  blood  is  abstracted,  the  congestion  can  be 
seen  to  terminate  in  a  short  time  in  complete  stasis.  While  venesection  in 
the  treatment  of  inflammation  has  been  discarded,  the  direct  abstraction  of 
blood  from  the  inflamed  part  has  proved  a  useful  therapeutic  resource. 
Nancrede  divided  a  large  vein  on  the  distal  side  of  the  circulation  in  the 
tongue  of  a  frog,  the  seat  of  an  intense  inflammation  artiflcially  produced. 
He  describes  the  tangible  therapeutic  effect  as  follows:  "The  effect  upon  the 
obstructed  vessels  was  flrst  an  oscillation  of  the  blood-disks,  then  an  occa- 
sional momentary  flow  of  blood,  then  suddenly  a  rapid  resumption  of  the  cir- 
culation, sweeping  out  the  blood-vessels  and  apparently  restoring  them  to 
their  normal  condition,  except  at  spots  where  the  agents  inducing  inflam- 
mation had  chemically  destroyed  the  vessels  or  coagulated  their  contents.^' 
Genzmer  showed  that  in  the  inflamed  mucous  membrane  of  a  frog  scarifica- 
tion hastened  resolution.  In  order  to  be  of  benefit  the  scarification  must 
be  made  through  the  inflamed  part,  so  as  to  unload  directly  the  dilated  and 
engorged  capillary  vessels,  and  on  this  account  this  method  of  treatment  is 
only  applicable  when  the  inflammation  is  superficial  and  affects  accessible 
parts.  Leeches  should  never  be  used,  as  infection  from  this  source  has  fre- 
quently resulted  disastrously.  The  scarificator  used  for  cupping  is  difficult 
to  keep  aseptic,  and  the  number  and  depth  of  the  scarifications  to  be  made 
are  not  under  the  control  of  the  surgeon,  and  for  these  reasons  this  instru- 
ment has  only  an  historical  interest  and  antiquarian  value.  The  scarification 
should  be  made  with  a  sharp  scalpel,  and  the  bleeding  encouraged  by  apply- 


150  PEINCIPLES    OF    SUEGEEY. 

ing  warm  water.  Scarification  is  followed  by  great  relief  in  inflammation 
of  accessible  mucous  membranes,  and  lias  recently  been  very  strongly  recom- 
mended in  the  treatment  of  erysipelas  for  the  purpose  of  preventing  the  ex- 
tension of  this  disease. 

In  the  different  forms  of  septic  inflammation  attended  by  severe  gen- 
eral symptoms  the  gastrointestinal  canal  often  participates  in  the  process, 
and  vomiting  and  diarrhoea  become  conspicuous  and  often  distressing  symp-' 
toms.  These  symptoms  should  not  be  checked,  as  they  indicate  an  attempt 
on  the  part  of  the  organism  to  eliminate  through  the  gastrointestinal 
mucous  membrane  microbes  and  toxins  which  have  reached  it  through  the 
general  circulation.  The  surgeon  should  assist  this  effort  by  administering 
a  few  doses  of  calomel,  followed  by  a  saline  cathartic,  which  will  often  con- 
trol the  vomiting  and  diarrhoea  more  promptly  by  removing  the  cause  than 
medicines  employed  to  arrest  the  process  of  elimination. 

Physiological  Rest. — One  of  the  most  urgent  indications  in  the  treat- 
ment of  inflammation  is  to  secure  for  the  part  affected  a  condition  approach- 
ing physiological  rest.  In  ulcerative  affections  of  the  gastrointestinal  canal 
the  patient  should  abstain  from  taking  food  by  the  stomach.  Fixation  of 
the  chest  by  means  of  broad  strips  of  adhesive  plaster  affords  great  relief  in 
pleuritis.  An  inflamed  joint  must  be  immobilized  by  some  kind  of  a  splint. 
A  chronic  cystitis  usually  yields  to  suprapubic  or  perineal  drainage  of  the 
bladder  after  all  other  measures  have  failed.  In  inflammatory  affections  of 
the  eye  exclusion  of  light  is  one  of  the  most  essential  features  of  successful 
treatment.  Patients  suffering  from  inflammatory  affections  of  the  tonsils, 
pharynx,  and  larynx  should  use  their  voice  as  little  as  possible.  In  cases  of 
acute  inflammation  of  the  brain  or  its  envelopes  the  patient  must  be  kept  in 
a  dark  room,  and  absolute  quietude  enforced. 

Elevation  of  Inflamed  Parts. — From  the  diminished  vis  a  tergo  on  the 
distal  side  of  the  capillary  vessels,  venous  engorgement  is  as  pronounced 
as  increased  arterial  tension  on  the  proximal  side  of  the  inflamed  capillary 
vessels,  and  elevation  of  the  inflamed  part  improves  the  vascular  disturb- 
ances by  the  force  of  gTavitation  favoring  the  return  of  venous  blood.  The 
importance  of  elevation  of  the  inflamed  part  becomes  manifest  in  the  treat- 
ment of  inflammatory  affections  of  the  extremities.  In  phlegmonous  inflam- 
mation of  the  hands  or  feet  the  throbbing  pain  is  always  aggravated  if  the 
limb  is  kept  in  a  dependent  position,  and  promptly  relieved  upon  placing 
it  in  an  elevated  position.  Elevation  not  only  alleviates  the  pain,  biit  is  at 
the  same  time  the  most  effective  means  of  removing  the  oedematous  swelling. 
If  necessary,  elevation  can  be  combined  with  suspension  in  order  to  secure 
more  perfect  rest  for  the  inflamed  part.  In  severe  acute  inflammation  it  is 
not  only  necessary  to  secure  rest  for  the  part  inflamed,  but  of  the  whole  body, 
and  in  such  cases  the  patient  must  observe  the  recumbent  position  in  bed. 


TREATMENT. 


151 


as  all  miiseular  movements  and  all  unnecessary  strain  upon  the  blood-vessels 
cannot  bnt  be  productive  of  harm  by  favoring  the  ingress  into  the  circula- 
tion of  microorganisms  and  their  toxins  from  the  seat  of  inflammation, 
or,  perhaps,  result  in  embolism  from  detachment  of  a  portion  of  a  thrombus: 
an  accident  which  possibly  might  not  have  occurred  otherwise. 

Application  of  Cold. — Cold  has  been  resorted  to  indiscriminately  and 
empirically  in  the  treatment  of  inflammation.  Cold  is  a  potent  agent  for 
good  or  harm,  according  to  the  stage  of  inflammation  during  which  it  is 
(employed.  The  sensation  of  heat,  both  subjective  and  objective,  naturally 
suggested  the  use  of  this  remedy.  The  application  of  cold  is  of  great  beneflt 
during  the  earliest  stage  of  inflammation,  at  a  time  when  exudation  is  only 
beginning  and  the  capillary  vessels  are  dilated  and  only  partially  obstructed. 


Fig.  75.— Cold  Coil.     (After  Esmarch.) 

Cold,  when  applied  under  these  circumstances,  becomes  a  valuable  remedial 
agent  (1)  by  producing  contraction  of  the  small  blood-vessels;  (2)  by  pro- 
ducing at  least  an  inhibitory  effect  upon  the  microorganisms  in  the  inflamed 
tissues.  The  contraction  of  blood-vessels  which  takes  place  imder  the  appli- 
cation of  cold  has  a  tendency  to  clear  the  capillaries  of  their  contents  and  to 
prevent  further  mural  implantation.  Microorganisms  can  only  multiply  at 
a  certain  temperature,  and  if  this  can  be  kept  at  a  point  low  enough  to  pre- 
vent their  increase  in  the  tissues  by  the  application  of  cold  this  agent  fulfills 
one  of  the  causal  indications  in  the  treatment  of  inflammation.  If,  however, 
stasis  has  already  taken  place  in  the  capillaries  first  affected,  the  appHcation 
of  cold  will  prove  harmful,  as  it  will  tend  to  prevent  the  formation  of  an 
adequate  collateral  circulation.     Cold  acts  most  beneficially  when  the  in- 


152 


PRINCIPLES    OF    SURGERY. 


flammation  is  located  in  the  superficial  parts,  but  its  prolonged  use  will  reach 
even  deep-seated  structures,  as  the  pleura,  peritoneum,  the  brain  and  its 
envelopes,  the  joints  and  bones.  When  it  appears  desirable  to  resort  to  the 
use  of  cold,  this  remedy  should  be  applied  in  the  form  of  an  ice-bag  or  cold 
coil.  The  part  to  which  the  ice-bag  is  to  be  applied  can  be  covered  with 
several  layers  of  a  wet  towel,  as  otherwise  the  prolonged  use  of  the  direct 
application  of  ice  may  freeze  the  skin.  The  sensations  of  the  patient  can 
usually  be  taken  as  a  safe  guide  as  to  the  length  of  time  it  shotild  be  con- 
tinued. 

Antiseptic  Fomentations.  —  The  ordinary  filthy  poultice  of  flaxseed, 
slippery  elm,  or  bread  and  milk  has  now  no  place  among  the  resources  of 


Fig.  76.— Cold  Coil  for  the  Head.    {After  Letter.) 

the  aseptic  surgeon.  The  common  poultice  is  a  hot-bed  for  bacteria,  and, 
as  such,  it  should  be  discarded.  In  the  treatment  of  an  ordinary  furuncle 
with  poultices,  I  am  sure  that  almost  every  surgeon  must  have  seen  occa- 
sionally the  development  of  innumerable  minute  daughter-furuncles  on  the 
surface  covered  by  the  poultice.  In  phlegmonous  inflammation  of  the 
fingers  or  hand  the  prolonged  use  of  the  poultice  is  followed  by  maceration 
of  the  skin,  extensive  oedema  of  the  superficial  structures,  a  flabby  condition 
of  the  granulation, — in  fact,  all  the  evidences  which  point  to  the  poultice  as 
a  means  of  favoring  the  extension  of  the  infective  process.  When  inflam- 
mation has  passed  beyond  the  stage  where  cold  exercises  a  favorable  influ- 
ence, or  where  cold  applications  increase  the  suffering,  warm  antiseptic 


TREATMENT.  153 

fomentations  should  be  employed.  The  surface  to  which  they  are  to  be  ap- 
plied should  be  thoroughly  cleansed  with  warm  water  and  potash-soap.  The 
antiseptic  solution  to  be  used  should  be  selected  according  to  the  age  of  the 
patient  or  the  area  affected,  with  a  special  view  of  guarding  against  the  ab- 
sorption of  a  toxic  dose  of  the  drug  employed.  Acetate  of  aluminum,  in  the 
strength  of  1  per  cent,  dissolved  in  sterilized  water,  is  a  safe  preparation 
under  all  circumstances.  Boric  and  salicylic  acids  are  efficient  and  safe  prep- 
arations. Greater  care  is  necessary  in  the  use  of  carbolic  acid  and  corrosive 
sublimate,  as,  when  concentrated  solutions  of  these  drugs  are  used  for  any 
length  of  time  in  infants,  the  aged,  or  persons  suffering  from  organic  disease 
of  the  kidneys,  there  is  danger  of  poisoning  from  absorption  through  the 
intact  skin.  In  children  and  marantic  persons  it  is  safer  to  use  acetate  of 
aluminum,  salicylic  or  boric  acid,  and  reserve  the  more  potent  antiseptics 
for  adults  suffering  from  circumscribed  inflammatory  lesions.  Hot  fomenta- 
tions act  as  derivatives  and  favor  the  formation  of  collateral  circulation;  at 
the  same  time  they  relieve  pain.  A  number  of  layers  of  hygroscopic  gauze 
or  flannel  cloth  are  wrung  out  of  one  of  these  antiseptic  solutions  and  applied 
over  the  affected  part,  and  for  the  purpose  of  retaining  the  heat  and  of  pre- 
venting evaporation  of  the  solution  the  compress  is  to  be  covered  either  with 
gutta-percha,  rubber  sheeting,  or  macintosh  cloth,  and  the  dressing  is  re- 
tained by  an  appropriate  bandage.  The  compress  is  removed  two  or  three 
times  a  day,  again  wrung  out  of  the  hot  solution,  and  reapplied  as  before. 
Absorption  through  the  skin  of  the  antiseptic  substance  used  may  have  a 
direct  influence  in  diminishing  the  intensity  of  the  cause  which  produced 
the  inflammation,  and  prepares,  in  an  admirable  manner,  the  fleld  for  any 
operation  which  may  become  necessary  later.  As  local  applications  alcohol 
and  some  of  the  silver  preparations  have  recently  been  strongly  recom- 
mended in  preventing  suppuration,  and  both  of  them  have  been  found  very 
efficient.    The  unguentum  Crede  has  had  a  very  extensive  trial. 

Antipyretics. — -If  the  rise  in  temperature  which  attends  many  of  the 
acute  inflammatory  affections  is  due  to  the  introduction  into  the  circula- 
tion of  phlogistic  substances  which  are  produced  by  the  action  of  the  micro- 
organisms in  the  inflamed  tissues,  it  is  not  difficult  to  conceive  that  its  arti- 
ficial reduction  by  the  internal  use  of  chemical  substances  is  not  followed  by 
any  permanent  benefit.  The  rational  treatment  of  the  fever  consists  of  such 
local  measures  as  will  remove  its  cause.  Antifebrin,  antipyrin,  salicylated 
soda,  quinine,  and  other  antipyretic  drugs,  when  employed  in  large  doses 
will  usually  reduce  the  temperature  several  degrees  for  a  few  hours,  but  this 
is  always  accomplished  at  the  expense  of  the  forces  which  are  laboring  to 
clear  obstructed  paths,  and  on  this  account  their  use,  on  the  whole,  has 
resulted  in  more  harm  than  good  to  the  patient.  Quinine  is  the  least  ob- 
jectionable of  the  drugs  which  have  been  mentioned,  and  in  the  beginning 


154  PRINCIPLES    OF    SURGERY. 

of  an  inflammation,  by  its  known  tonic  effect  on  the  small  blood-vessels, 
when  administered  in  a  large  dose,  has  a  favorable  effect  in  preventing  rapid 
dilatation  of  and  stasis  within  the  capillary  vessels.  If  used  at  all,  it  should 
be  given  in  a  decided  dose, — 1  gramme,  in  solution, — immediately  or  soon 
after  the  development  of  the  first  symptoms.  Sponging  the  surface  of  the 
body  with  warm  water  and  the  use  of  warm  baths  are  the  most  rational  anti- 
pyretics, as  these  simple  measures  do  not  weaken  the  heart's  action,  while 
they  have  a  decided  effect  on  the  temperature,  and  at  the  same  time  add  to 
the  comfort  of  the  patient  and  favor  the  elimination  of  microbes  through 
the  excretory  organs  of  the  skin.  As  the  kidneys  are  known  to  eliminate 
microorganisms  that  reach  them  through  the  general  circulation,  their  func- 
tion should  be  carefully  inquired  into,  and  if  the  secretion  of  the  urine  is 
scanty,  diuretics,  like  liquor  ammonise  acetatis  or  acetate  of  potash,  should 
be  given. 

Stimulaiits. — Just  as  soon  as  symptoms  of  sepsis  develop  in  the  course 
of  an  inflammation,  alcoholic  stimulants  should  be  freely  administered  to 
meet  in  time  the  dangers  incident  to  heart-failure.  Stimulants  have  largely 
taken  the  place  of  antiphlogistics  at  the  present  time  in  the  treatment  of 
septic  inflammations.  Brand}^,  cognac,  or  whisky,  not  in  measured  doses,  but 
given  in  quantities  large  enough  to  produce  the  desired  effect  on  the  heart, 
are  given  at  intervals  of  one  or  two  hours.  Champagne  is  a  more  diffusible 
stimulant,  and  is  to  be  resorted  to  when  the  stomach  does  not  tolerate  other 
alcoholics.  In  chronic  cases  Tokay  or  Greek  sherry  is  to  be  preferred.  In 
wasting  diseases  a  good  quality  of  beer,  ale,  or  porter  will  do  excellent  serv- 
ice. In  cases  where,  from  any  cause,  the  heart's  action  is  suddenly  dimin- 
ished, strychnine,  camphor,  or  musk  can  be  administered  subcutaneously  to 
bridge  over  the  time  for  the  employment  of  more  substantial  stimulants. 

Diet. — The  treatment  of  inflammation  by  starvation  has  been  abolished 
long  ago.  The  strength  of  the  patient  must  be  sustained  in  time  by  a  nutri- 
tious, well-selected  diet.  Animal  broths,  beef-tea,  and  milk  should  be  freely 
given  from  the  very  beginning,  and  if  more  substantial  food  can  be  digested 
it  should  not  be  withheld.  Oysters,  eggs,  finely-scraped  raw  meat  or  rare 
roast  are  excellent  articles  of  food  for  patients  whose  strength  is  being  un- 
dermined by  debilitating,  suppurative  affections.  If  the  stomach  does  not 
retain  food,  the  patient  should  be  nourished  by  rectal  enemata  of  peptonized 
milk  and  beef-tea  in  quantities  not  exceeding  4  ounces,  given  alternately, 
every  eight  hours.  Ripe  oranges  and  grapes  are  most  always  grateful  to  the 
patient,  and  their  use  should  never  be  prohibited,  unless  the  gastrointestinal 
canal  is  the  seat  of  inflammation.  In  the  treatment  of  acute  inflammatory 
affections  of  the  peritoneum  and  the  gastrointestinal  canal  stomach  feeding 
must  be  suspended,  and  if  need  be,  rectal  enemata  should  take  its  place. 

Tonics  and  Alteratives. — In  protracted  inflammatory  affections  tonic 


TREATMENT.  155 

doses  of  quinine  are  indicated.  Tincture  of  chloride  of  iron  is  an  excellent 
remedy  after  the  acute  febrile  symptoms  have  subsided.  Under  similar  cir- 
cumstances one  or  more  of  the  bitter  tonics  can  be  given  with  benefit  if  the 
appetite  is  defective.  If  there  is  any  history  of  specific  disease,  a  thorough 
antisyphilitic  treatment  will  often  produce  a  marked  effect  for  the  better 
on  the  inflammatory  process.  Catarrhal  inflammation  in  rheumatic  patients 
is  favorably  influenced  by  antirheumatic  remedies.  Syphilitic  lesions  are  to 
be  treated  by  potassic  iodide  and  small  doses  of  corrosive  sublimate.  Tuber- 
cular affections  call  for  guaiacol,  arseniate  of  iron,  syrup  of  iodide  of  iron, 
and,  if  the  patient's  stomach  can  tolerate  it,  pure  codliver-oil.  The  latter 
drug  should  be  given  alone,  and  not  in  emulsion,  in  gradually-increasing 
doses  an  hour  and  a  half  after  each  meal. 

Anodynes. — Eemedies  to  relieve  pain  must  always  be  used  with  caution, 
as  in  painful  chronic  affections  their  prolonged  use  frequently  engenders  a 
habit.  The  cause  of  pain  must  be  sought  for,  and,  if  possible,  removed  by 
local  measures.  In  acute  inflammation  pain  indicates  tension  in  the  in- 
flamed part,  and  prompt  relief  is  obtained  by  subcutaneous  or  open  incision. 
Periostitis  and  paronychia  should  be  treated  by  this  method.  In  superflcial 
inflammations  scarification  answers  the  same  purpose.  If  opiates  are  used, 
a  decided  dose  is  better  than  smaller  doses  frequently  repeated.  The  ano- 
dyne effect  of  opium  is  increased  by  the  addition  of  a  minute  dose  of  atro- 
pine. Chloral  and  potassic  bromides  are  to  be  preferred  to  opium  to  relieve 
the  pain  of  intracranial  lesions.  Phenacetin  in  ^/o-gramme  doses  is  a  very 
excellent  anodyne  in  cases  of  peripheral  neuritis.  Inhalations  of  chloroform 
to  allay  intense  pain  should  never  be  resorted  to  except  by  the  direction  of 
and  under  the  personal  supervision  of  a  competent  physician.  Local  appli- 
cations of  anodynes  are  often  effective  in  the  treatment  of  superficial  infiam- 
mation  and  neuralgic  affections.  Chloroform  liniment  and  menthol  are  most 
frequently  prescribed  for  this  purpose. 

Massage.  —  In  chronic  infiammatory  affections  systematic  massage, 
scientifically  practiced,  is  an  exceedingly  important  and  valuable  therapeu- 
tic resource.  It  stimulates  the  surrounding  vessels  to  increased  action,  and 
exerts  a  potent  infiuence  in  restoring  the  normal  circulation  in  the  affected 
capillary  vessels,  and  always  promotes  absorption.  The  masseur  should  be 
instructed  to  apply  some  absorbent  preparation  before  making  the  manipula- 
tions, as  the  endermic  use  of  absorbent  drugs  in  this  manner  will  increase 
the  efficacy  of  the  treatment.  A  drachm  of  potassic  iodide  or  half  a  drachm 
of  iodoform  to  an  ounce  of  lanolin  will  be  an  excellent  preparation  for  this 
purpose.  Cold  and  hot  douches,  passive  and  active  motion,  combined  with 
massage,  will  often  expedite  a  cure. 

Counter-irritation.— Like  so  many  other  time-honored  methods  of  treat- 
ment, counter-irritation  in  the  treatment  of  acute  inflammation  has  almost 


156  PRINCIPLES    OF    SUEGERY. 

entirely  gone  out  of  use.  In  chronic  inflammation^,  blistering  and  painting 
with  the  tincture  of  iodine  will  at  least  satisfy  the  patient,  if  no  good  result 
from  them;  and  if  he  do  not  recover,  he  is  at  least  prevented  from  passing 
into  the  hands  of  charlatans  until  the  time  has  arrived  to  resort  to  more 
effective  and  radical  measures.  Kocher  praises  the  application  of  the  actual 
cautery  in  the  treatment  of  chronic  tubercular  osteomyelitis  and  synovitis. 
The  seton  and  moxa  have  fallen  into  well-merited  disuse  for  all  time  to 
come. 

Ignipuncture. — In  many  chronic  affections,  where  the  inflammatory 
exudation  remains  stationary  for  a  long  time,  multiple  punctures  with  the 
needle-point  of  a  Paquelin  cautery,  made  under  strict  antiseptic  precautions, 
will  have  a  prompt  effect  in  mitigating  the  primary  cause,  as  well  as  in 
promoting  absorption. 


CHAPTER  VI. 

Pathogenic  Bacteria. 

Bacteria,  microorganisms,  microbes,  and  germs  are  synonymous 
terms  for  certain  minute,  microscopical,  vegetable  organisms  which,  when 
introduced  into  the  living  body,  produce  the  fever  and  the  tissue-changes 
described  in  the  preceding  chapter.  For  a  time  it  was  claimed  that  these 
minute  organisms  belonged  to  the  animal  kingdom,  as  some  of  them  were 
seen  to  possess  spontaneous  movements;  but  now  it  is  generally  agreed  that 
they  are  minute  plants,  and  botanists  have  made  great  progress  in  perfecting 
a  scientific  classification.  Among  the  men  who  have  developed  this  part  of 
botany,  the  names  of  Cohn,  Zopf,  and  Nageli  stand  preeminent. 

CLASSIFICATION. 

The  pathogenic  bacteria  which  will  claim  our  attention  belong  to  the 
class  known  as  schizomycetes  (Spaltpilze).     In  diameter  they  vary  from 
0.001  to  0.004  millimetre,  and  are  composed  largely  of  an  albuminoid  sub- 
stance called  by  Nencki  mycoprotein.    Toward  the  periphery  this  substance 
becomes  firmer,  and  forms  a  gelatinous  envelope,  a  sort  of  a  membrane, 
which  is  said  to  contain  cellulose,  and,  in  some  instances,  even  fatty  material. 
The  outer  surface  of  bacteria  is  frequently  covered  with  a  viscid  substance, 
by  which  many  of  them  are  often  held  together  in  a  mass  or  group,  tech- 
nically called  zoogloea.    Each  bacterium  represents  a  cell,  although  the  pres- 
ence of  a  nucleus,  or  something  representing  such  a  structure,  has  not  been 
demonstrated;    but  its  cellular  structure  is  made  evident  by  its  intrinsic 
power  of  germination  or  reproduction  when  surrounded  by  the  necessary 
conditions  for  its  groAvth.    Some  of  the  bacteria  are  provided  with  processes, 
or  cilia,  by  which,  when  suspended  in  a  fluid,  movements  are  accomplished; 
in  others  motion  is  entirely  dependent  on  molecular  movements  described 
by  Brown.     Nageli,  and  formerly  Billroth,  claimed  that  all  bacteria  had  a 
common  botanical  source,  and  that  the  different  forms  and  actions  only  rep- 
resented alteration  of  form  of  action  of  the  same  plant  at  different  stages  of 
development  and  under  different  circumstances, — in  other  words,  that  a 
coccus  could  be  transformed  into  a  bacillus,  and  vice  versa;  and  that  in  one 
instance  the  same  plant  caused  fermentation,  in  another  putrefaction,  and 
that  all  infective  diseases  were  caused  by  the  same  microbe.    Buchner  main- 
tained that,  by  cultivation  in  different  nutrient  media,  he  was  able  to  trans- 
form the  dangerous  bacillus  of  anthrax  into  the  harmless  bacillus  subtilis, 
and,  again,  the  latter  into  the  former.     Cultivation  and  inoculation  experi- 

(157) 


158 


PRINCIPLES    OF    SURGERY. 


ments  on  a  large  scale  by  most  careful  observers  have  shown  conclusively 
that  such  transformations  never  take  place,  and  that  each  microbe  not  only 


<  •  •        • 


•••»• 


..It,  -!•••••  •••••••••• 

Mtti*  • 


N 


v;.^••••• 


%«.»»«»*»^ 


•-:«  3 


'IvV 


-^ 


^3        i^3        \/ 


4^'^  ^^ 


Fig.  77.— Different  Forms  of  Bacteria.    A,  cocci;    B,  bacilli;    C,  spirilli.     {Baumgarten.) 

always  retains  its  shape,  but  also  its  specific  pathogenic  properties.  Pus- 
and  other  microbes  have  been  cultivated  through  thirty  and  more  genera- 
tions without  suffering  any  morphological  deviations  or  losing  any  of  their 


MULTIPLICATION"    OF    BACTEEIA.  159 

inherent  characteristic  pathogenic  properties.  The  three  principal  morpho- 
logical forms  of  bacteria  discovered  up  to  the  present  time,  and  which  have 
been  demonstrated  as  causes  of  disease,  are:  (1)  the  ball  (coccus);  (2)  rod 
(bacillus);  (3)  corkscrew  (spirillum).  As  illustrations  for  these  different 
forms,  de  Bary  very  appropriately  takes  the  billiard-ball,  lead-pencil,  and 
corkscrew. 

The  surgeon  has  to  deal  only  with  the  first  two  forms:  the  cocci  and 
bacilli.  Modifications  of  form  are  frequently  met  with,  as  an  oblong  coccus 
closely  resembles  a  short  bacillus,  and  a  short,  broad  bacillus  with  rounded 
ends  approaches  the  coccus  form.  Again,  a  double  coccus,  or  diplococcus, 
with  ill-defined  constriction  at  the  point  of  junction,  might,  from  superficial 
examination,  be  mistaken  for  a  bacillus  (Fig.  77,  A,  2).  More  than  two 
cocci  in  a  row,  or  a  chain  of  cocci,  are  called  a  streptococcus  {A,  3).  Four 
cocci  arranged  in  the  form  of  a  square  are  called  a  micrococcus  tetragones 
{A,  4).    Cocci  arranged  in  the  form  of  a  bunch  of  grapes  are  called  staphylo- 


Fig.  78.— Zoogloea. 

cocci  {A,  6).    An  irregular  mass  of  cocci,  when  at  rest  and  held  together  by  a 
viscid  substance,  is  described  as  a  zoogloea. 

MULTIPLICATION    OF    BACTERIA. 

Bacteria  multiply  with  great  rapidity  in  tissues  presenting  favorable 
conditions  for  their  growth,  or  in  proper  nutrient  media  kept  at  a  temper- 
ature approaching  that  of  the  body.  Multiplication  takes  place  either  by 
fissure  or  segmentation,  by  the  production  of  spores,  or  both  of  these  meth- 
ods. The  bacillus  of  anthrax  multiplies  by  fission  in  the  body,  by  spores 
outside  of  the  body. 

Fission. — The  round  or  globular  bacteria, — the  cocci, — as  far  as  we 
know,  multiply  only  by  fission.  The  cell  elongates  prior  to  segmentation, 
when  a  constriction  appears  in  the  centre,  which,  by  becoming  deeper  and 
deeper,  finally  results  in  complete  division  of  the  cell  into  two  equal  halves, 
which  soon  attain  the  size  of  the  mother-cell,  and,  in  turn,  again  undergo 
the  same  process.  If  the  new  cells  remain  adherent  and  arrange  themselves 
in  the  form  of  a  chain,  a  streptococcus  is  formed.  Fliigge  observed  complete 
division  of  a  coccus  in  bouillon,  kept  at  a  temperature  of  35°  C,  in  twenty 


160  PEINCIPLES    OF    SUKGERY. 

minutes.  If  it  should  require  one  hour  to  complete  segmentation  and  for 
the  new  cell  to  attain  maturity,  a  single  coccus  multiplying  by  fission,  ac- 
cording to  Cohn,  during  one  day,  would  produce  sixteen  millions  of  cocci, 
and  at  the  end  of  the  second  day  the  product  would  represent  two  hundred 
and  eighty-one  billions  in  number,  and  at  the  end  of  three  days  the  extraor- 
dinary number  of  forty-seven  trillions  would  be  reached.  Eod  bacteria 
which  reproduce  themselves  by  fission  undergo  transverse  segmentation  in 
the  middle,  and  after  complete  separation  each  segment  grows  to  the  size  of 
the  parent-cell  before  the  process  repeats  itself. 

Spores. — The  spores  of  bacteria  represent  the  seed  of  flowering  plants. 
Each  spore  develops  into  a  bacterium,  and  thus  one  crop  after  another  is 
produced,  the  multiplication  increasing  with  the  number  of  bacteria  in  the 


V 


/ 

( 

8 

\ 

Fig.  79.— Endogenous  Spore-production  in  BaciUus  Anthracis  CuUivated  upon  Meat- 
Infusion  Peptone-Gelatin.    X  950.     {Baumgarten.) 

soil.  Most  of  the  bacilli  multiply  by  spores.  Fructification  again  takes 
plar^e,  either  within  the  protoplasm  of  the  cell  (endospore)  or  at  one  or  both 
extremities  of  the  cell  (endspore).  Fructification  is  often  preceded  by  a  rapid 
elongation  of  the  bacillus.  Multiple  endospores  usually  form  in  one  bacillus 
simultaneously.  The  first  evidences  of  the  formation  of  spores  within  the 
protoplasm  of  a  bacillus  is  indicated  by  the  appearance  of  circumscribed 
points  of  cloudiness  at  equidistant  points. 

After  the  expiration  of  twenty  hours  the  bacillus  appears  like  a  string 
of  pearls,  each  segment  of  which  represents  a  fully-developed  spore.  After 
this  the  segments  separate  and  each  spore  develops  into  a  bacillus.  If  the 
bacillus  reproduce  itself  by  a  single  endospore,  it  does  not  elongate  before 
fructification,  but  increases  in  diameter,  especially  in  the  centre,  so  that  it 


MULTIPLICATION    OF    BACTEEIA.  1-61 

assumes  the  shape  of  a  spindle;  while,  equidistant  from  its  ends,  changes  are 
observed  in  the  protoplasm  which  indicate  the  beginning  of  spore-formation. 
If  the  bacilhis  multiply  by  terminal  fructification,  one  or  both  of  its  ends 
enlarge,  become  club-shaped,  and  the  spores  pass  through  the  same  stages  of 
development  as  the  endospores,  and  they  are  liberated  in  the  same  manner, 
by  liquefaction  of  the  cell-membrane  surrounding  them.  Bacteriologists  are 
familiar  with  the  fact  that  spores  possess  a  greater  power  of  resistance  to 
germicidal  agents  than  the  bacilli  which  produced  them.  Mature  bacteria 
are  always  destroyed  by  a  temperature  of  77°  C;  most  of  them  succumb 
when  exposed  to  a  heat  of  50°  to  55°  C.  On  the  other  hand,  some  of  the 
spores  are  known  to  survive  a  temperature  of  100°  to  120°  C. 

Macfayden  and  Bloxall  have  made  a  careful  examination  into  the  tem- 
perature most  congenial  to  the  gTowth  of  bacteria,  and  have  found  that  some 
of  them  germinate  most  vigorously  at  a  high  temperature,  and  they  apply 
to  such  the  designation  thermophilic  bacteria.  Experiments  were  made  with 
temperatures  ranging  from  60°  to  65°  C.  Such  bacteria  were  found  in  the 
fgeces  of  man  and  the  lower  animals,  in  Thames  water  and  mud,  street-dust, 
straw  and  sea-water.     All  the  organisms  isolated  were  bacilli,  some  twenty 


esi 


'^3 

Fig.  80.— Spore  of  BaciUus  of  Anthrax.    X  6-700.    S,  ripe  spore  before  germination;  1,  2,  3, 
three  successive  stages  of  germinating  spore;    3,  young  rod.    (De  Bary.) 

different  forms  were  isolated.  The  first  culture  was  obtained  at  a  tempera- 
ture from  40°  to  42°  C.  The  most  favorable  temperature  was  from  60°  to 
65°  C.  A  temperature  of  75°  C.  proved  destructive  to  all  of  them.  The 
wide  distribution  and  active  fermentative  properties  of  thermophilic  bacteria 
point  to  their  fulfilling  some  important  function  in  the  economy  of  nature. 
Sternberg  has  determined  the  thermal  death-point  of  the  following 
pathogenic  bacteria: — 

Fahr. 

Bacillus  anthracis  (Chaveau) 129.2° 

Bacillus-anthracis  spores 212.0° 

Bacillus  tuberculosis  (Schill  and  Hisclier) 212.0° 

Staphylococcus  albus 143.6° 

Staphylococcus  pyogenes  aureus 136.4° 

Staphylococcus  pyogenes  citreus 143.6° 

Streptococcus  erysipelatosus  129.2° 

Gonococcus 140.0° 

In  all  experiments,  with  the  exception  of  the  bacillus  of  tuberculosis, 
the  microbe  was  subjected  to  the  specified  heat  for  ten  minutes;  the  tubercle 
bacillus  was  destroyed  in  four  minutes.    Such  resisting  spores  are  often  not 


162  PKINCIPLES    OF    SUEGEKY. 

destroyed  by  boiling  continued  for  several  minutes,  and  yield  only  slowly 
and  frequently  imperfectly  to  germicidal  chemical  agents.  Surgeons  are 
aware  that  such  spores  may  remain  dormant  in  the  body  for  years  without 
giving  rise  to  any  symptoms  until  aroused  to  activity  by  surrounding  con- 
ditions favorable  to  their  growth  and  development. 

CULTIVATIOISr    OF    BACTERIA. 

The  first  cultivation  experiments  were  made  with  fluid  nutrient  sub- 
stances, such  as  bouillon,  different  animal  broths,  and  solutions  of  sugar. 
Koch  introduced  solid  nutrient  media,  which  not  only  serve  as  food  for  the 
bacteria,  but  at  the  same  time  present  the  great  advantage  that  the  colonies 
can  be  seen  with  the  naked  eye,  and  their  macroscopical  appearances,  as  well 
as  the  visible  action  of  the  bacteria  on  the  nutrient  substance,  often  are  suffi- 
cient to  convey  reliable  information  to  enable  the  observer  to  form  a  posi- 
tive conclusion  in  reference  to  the  kind  of  microbes  of  which  the  colonies 
are  composed.  In  fluid  nutrient  media  the  bacteria  cause  turbidity,  or  they 
appear  as  a  thin  film  on  the  surface;  or  zoogloea  masses  show  themselves  as 
swimming  flocculi;  or,  finally,  when  the  fluid  has  been  exhausted  of  its 
nutrient  supply  the  spores  settle  at  the  bottom  of  the  vessel  and  appear  as  a 
pulverulent  deposit.  Upon  solid  nutrient  media  each  kind  of  bacteria  ap- 
pears as  an  isolated,  distinct  colony,  and  as  such  can  be  recognized  by  the 
naked-eye  appearances. 

The  substance  used  first  by  Koch  as  a  solid  medium,  and  which  is  now 
used  more  than  any  other,  was  gelatin.  Later,  a  jellj^-like  substance  called 
agar-agar,  obtained  from  several  sea-weeds  on  the  coasts  of  Japan  and  India, 
was  found  superior  to  gelatin  where  a  higher  than  ordinary  temperature  was 
required  to  cultivate  certain  microbes.  Edington  prefers  a  gelatin  made  of 
Irish  moss  to  agar-agar,  as  it  is  more  transparent.  Some  microbes  that  will 
not  grow  upon  gelatin  vegetate  luxuriantly  on  solid  blood-serum.  The  tu- 
bercle l:)acillus  grows  equally  well  upon  solid  blood-serum  and  glycerin  agar- 
agar.  This  latter  substance  is  easily  prepared,  and  is  made  by  adding  6  per 
cent,  of  pure  glycerin  to  the  ordinary  agar  medium. 

The  busy  practitioner,  who  has  no  time  to  prepare  the  media  used  in 
laboratory  work,  can  do  good  bacteriological  work  b}^  using  sterilized  potato 
or  bread-paste.  The  potato  is  the  best  medium  for  the  cultivation  of  chro- 
mogenous  bacteria,  as  upon  this  substance  the  color  is  preserved.  The 
potato  is  scrubbed  with  a  hard  brush  under  a  stream  of  water.  It  is  then 
left  in  a  solution  of  corrosive  sublimate  (1  to  1000)  for  an  hour  or  so  to 
disinfect  its  surface.  With  a  knife  rendered  sterile  by  passing  it  through  the 
flame  of  a  Bunsen  lamp,  a  quadrilateral  piece  is  cut  from  the  centre,  and  is 
rapidly  transferred  on  the  knife  to  a  glass  capsule  previously  sterilized  by 
heat.     Capsule  and  ]:)otato  are  next  placed  in  a  steam  sterilizer,  when  the 


CULTIVATIOX    OF    BACTERIA. 


16^ 


simple  apparatus  is  ready  for  inoculation.  Inoculation  is  done  by  charging 
the  point  of  an  aseptic  needle  with  the  culture  or  substance  containing  the 
microbes,  and,  after  lifting  the  capsule  half  up,  a  number  of  streaks  are  made 
with  the  needle  upon  the  surface  of  the  potato.  A  potato-paste,  made  by 
adding  a  sufficient  quantity  of  distilled  water  to  the  interior  portion  of  boiled 
potatoes  to  make  a  paste,  is  used  in  the  same  manner  and  answers  the  same 
purpose  as  sterilized  raw  potato. 

Bread-paste  is  made  of  stale,  coarse  bread,  thoroughly  dried  in  an  oven, 
but  not  roasted.  It  is  pulverized  in  a  clean  mortar  and  the  powder  made  into 
a  paste  by  adding  distilled  water.  The  paste  is  transferred  to  sterile  glass 
capsules  and  used  in  the  same  manner  as  potato-paste.  If  it  is  employed 
for  the  culture  of  bacteria,  it  must  be  neutralized  with  a  solution  of  carbonate 


iiL^«'ail 


Fig.  81. — Gelatin  Cultures  following  Surface  Inoculation.     {Fliigge.) 


of  soda.  Some  microbes  possess  the  faculty  of  liquefying  the  gelatin;  others 
remain  as  solid  cultures  upon  the  surface  of  the  medium,  or  its  interior. 
Free  access  of  oxygen  to  the  seat  of  inoculation  is  essential  for  the  growth 
of  some  microbes,  and  these  were  termed  by  Pasteur  aerobic,  while  those  that 
germinate  with  exclusion  of  oxygen  he  called  anaerobic.  The  former  class 
germinate  on  the  surface  of  the  m^edia  with  or  without  liquefaction  of  the 
soil.  If  microbes  of  this  kind  are  inoculated  by  scratching  the  surface  of 
the  medium  with  the  point  of  a  needle  charged  with  them,  the  culture  ap- 
pears first  at  isolated  points  (Fig.  81,  A),  which  by  increase  in  size  become 
confluent  and  occupy  as  a  solid  mass  the  whole  track  made  by  the  needle 
{B,  C).  A  microbe  Avhich  requires  oxygen  and  grows  only  in  the  presence 
of  this  gas  is  said  to  be  aerobic.    A  facultative  anaerobic  microorganism  grows 


164 


PEINCIPLES    OF    SUKGERY. 


and  develops  either  in  the  presence  of  oxygen  or  in  its  absence.  An  anaerobic 
microbe  cannot  grow  in  the  presence  of  oxygen  and,  consequently,  grows  only 
below  the  surface  of  solid  nutrient  media.  Microbes  which  usually  lead  a 
saprophytic  existence,  but  which  can  also  thrive  within  the  living  body,  are 
called  facultative  parasites.  The  bacillus  of  lepra  is  a  strict  parasite,  while 
the  typhoid  bacillus,  the  cholera  spirillum,  etc.,  are  facultative  parasites, 
inasmuch  as  they  are  capable  of  living  and  multiplying,  under  favorable  con- 
ditions, external  to  the  bodies  of  living  animals. 

In  making  inoculations  with  anaerobic  bacteria  the  gelatin  is  punctured 
with  a  needle,  charged  as  before,  to  some  depth,  and  isolated  colonies  appear 
in  the  track  made  by  the  needle,  which  by  confluence  form  a  continuous  un- 
interrupted culture  the  whole  depth  of  the  needle,  which  increases  in  diam- 


Fig.  82.— Cultures  in  Gelatin  growing  in  the  Track  made  by  the  Needle.     (Flilgge.) 

eter  by  extension  in  a  peripheral  direction.     Superficial  cultures  are  called 
streak  cultures;    deep  cultures,  stab  cultures. 

All  cultivation  experiments  must,  of  course,  be  conducted  under  strictest 
aseptic  precautions,  as  otherwise  there  is  great  danger  of  contamination 
of  the  cultures  by  the  accidental  ingress  of  other  microbes,  especially  of  some 
forms  of  fungi. 


ESSENTIAL    CONDITION    FOE    GROWTH    OF   BACTERIA. 

For  the  germination  of  bacteria,  besides  a  proper  nutrient  substance 
the  other  conditions  which  enable  the  growth  of  other  plants  from  seed  are 
necessary,  viz.:  moisture  and  a  certain  degree  of  heat.  Inspissation  of  a 
solid  nutrient  medium  arrests  further  development  of  a  culture.     Bacteria 


ACTION    OF   BACTERIA    ON    TISSUES    OF    THE    BODY.  165 

cannot  grow  upon  a  perfectly  dry  medinm.  Most  microbes  germinate  best 
at  a  temperature  corresponding  to  blood-heat,  but  in  this  respect  the  differ- 
ent kinds  show  great  variance,  as  some  vegetate  at  10°  C,  while  the  growth 
of  others  will  continue  at.  65°  C.  Acids  appear  to  produce  an  inhibitory 
effect  on  the  process  of  germination.  Laplace  has  utilized  this  fact  and  ad- 
vises the  addition  of  citric  acid  to  solutions  of  corrosive  sublimate  to  in- 
tensify its  germicidal  properties.  It  is  well  known  that  the  gastric  juice 
suspends  the  growth  of  most  bacteria.  Bacteria  which  live  on  dead  sub- 
stances exclusively  are  called  saprophytes.  Bacteria  which  feed  on  dead  sub- 
stances and  can  exist  in  the  living  tissues  only  at  a  certain  stage  of  develop- 
ment are  called  facultative  parasites,  in  comparison  with  the  obligatory  para- 
sites, which  multiply  exclusively  in  the  living  tissues.  As  representatives  of 
the  former  can  be  enumerated  the  bacillus  of  anthrax  and  cholera,  which, 
under  favorable  conditions,  can  multiply  outside  of  the  body,  while  the  bacil- 
lus of  tuberculosis  germinates  only  in  the  living  body. 

It  has  recently  been  ascertained  that  some  bacteria  exert  a  decided  effect 
on  toxic  alkaloids.  Thus,  S.  Holenghi  found  that  the  potency  of  weak  atro- 
pine solutions  in  bouillon  was  progressively  weakened  by  cultures  of  the 
bacillus  coli  commune  and  other  putrefactive  bacteria.  Solutions  of  strych- 
nine showed  at  first  an  increase  to  double  or  treble  the  original  toxicity, 
which  was  estimated  by  observing  the  degree  of  dilution  in  which  a  distinct 
physiological  effect  was  still  obtainable,  followed  by  a  gradual  diminution 
after  the  end  of  the  first  week. 

ACTION    OF    BACTERIA    ON    TISSUES    OF    THE    BODY. 

The  action  of  pathogenic  bacteria  on  the  tissues  is  a  twofold  one.  In 
the  first  place,  they  abstract  from  the  body  a  part  of  its  essential  constituents; 
for  example,  albuminous  substances,  carbohydrates,  oxygen,  etc.  These  sub- 
stances are  not  only  taken  from  the  fluids  of  the  body,  as  the  blood  and 
lymph,  but  also  directly  from  the  protoplasm  of  the  cells.  In  the  second 
place,  they  produce  in  the  body  toxic  agents  from  their  action  on  the  albu- 
minoid substances.  The  decomposition  of  albuminoid  substances  by  the 
action  of  bacteria  results  in  the  formation  of  ammonia  and  its  derivatives, 
the  different  amines,  COo,  HoS,  indol,  scatol,  phenol,  asparagin,  leucin, 
tyrosin,  etc. 

Toxins  and  Ptomaines. — The  common  names  for  the  toxic  substances  of 
bacterial  origin  are  ptomaines  and  toxins.  Brieger  has  isolated  a  number 
of  ptomaines  from  cultures  of  different  bacteria,  and  Hoffa  followed  him  in 
the  same  kind  of  work.  Vaughn,  of  this  countr}^,  has  written  a  valuable 
work  on  this  subject,  which  should  be  read  by  all  who  wish  to  become  familiar 
with  modern  surgical  pathology.  Brieger  has  isolated  a  number  of  toxic 
alkaloids — cadaverin,  neurin,  muscarin,  and  mydalein — which  are  intensely 


166  PKINCIPLES    OF    SUEGEKY. 

toxiC;,  Avhile  the  derivatives  of  ammonia — dimethylamin^  trimethylamin,  and 
triathylamin — are  much  less  dangerous  substances.  The  ptomaines  being 
soluble  substances,  are  readily  absorbed,  and  when  introduced  into  the  cir- 
culation produce  fever  and  symptoms  of  sepsis.  The  toxins  of  the  bacillus 
of  tetanus  act  principally  upon  the  central  nervous  system,  producing  char- 
acteristic tonic  and  clonic  spasms  of  definite  groups  of  muscles.  The 
toxins  also  produce  a  definite  local  effect, — thus,  the  toxins  of  pus-microbes 
transform  the  leucocytes  and  embryonal  cells  into  pus-corpuscles,  those 
of  the  microbe  of  progressive  gangrene  destroy  the  protoplasm  of  the  cell- 
body  directly,  while  the  toxic  substances  of  the  microbes  of  chronic  infect- 
ive diseases  transform  the  fixed  tissue-cells  into  embryonal  or  granulation 
cells.  Some  -of  the  microbes  remain  in  the  tissue  at  the  seat  of  infection; 
others  localize  in  the  lymphatic  channels;  while,  finally,  others  enter  the 
general  circulation  and  multiply  in  distant  organs.  The  production  of  pto- 
maines and  toxins  usually  take^  place  in  the  tissues  in  which  localization 
takes  place. 

ANTITOXINS. 

Much  has  been  done  during  the  last  decade  by  bacteriologists  to  discover 
a  bacteriological  product  that  would  antagonize  the  pathogenic  action  of  dis- 
ease-producing microbes.  These  bacterial  therapeutic  agents  are  called  anti- 
toxins. This  field  is  an  immense  one,  and  its  faithful  cultivation  is  full  of 
promise.  Much  has  been  accomplished;  much  more  awaits  the  patient  in- 
vestigators. The  greatest  triumph  so  far  has  been  achieved  by  Behring. 
His  discovery  has  robbed  diphtheria  of  its  many  terrors.  Thousands  of  chil- 
dren owe  their  lives  to  the  diphtheria  antitoxin. 

The  antitoxins  which  have  been  found  efficient  unite  with  the  toxins 
and  form  harmless  chemical  compounds,  as  opposed  to  the  theory  that 
antitoxins  are  curative  by  their  stimulating  action  on  the  tissues;  in  other 
words,  by  exciting  an  active  process  of  phagocytosis. 

The  reactions  obtained  outside  of  the  body  indicate  a  direct  chemical 
action  between  toxins  and  antitoxins,  ferments  and  antiferments,  of  various 
kinds.  Toxins  are  akin  to  enzymes  by  their  great  activity  in  small  quanti- 
ties and  by  their  instability  in  the  presence  of  chemical  and  physical  agents; 
but  the  exact  nature  and  mode  of  action  of  both  are  as  yet  but  imperfectly 
understood. 

Behring,  in  discussing  the  quantitative  relations  of  the  combination 
between  tetanus  toxin  and  tetanus  antitoxin  in  the  body  of  a  living  guinea- 
pig,  concludes  that  the  chemical  union  of  the  two  substances  and  the  neu- 
tralization of  the  toxin  occurs  wherever  in  the  body  the  tAVO  substances  come 
together.  In  the  interval  before  chemical  union  of  the  poison  and  the  anti- 
toxin occurs,  some  of  the  poison  in  the  blood  may  pass  out  of  the  vessel  and 


ATTENUATION  OF  PATHOGENIC  BACTERIA.  167 

thus  escape  "union  with  antitoxin  in  the  blood.  In  order  to  reach  the  extra- 
vascnlar  toxin  the  antitoxin  must  also  pass  through  the  yessel-walls.  This 
does  occur^  and  in  greater  degree  the  more  concentrated  the  antitoxin  in 
the  blood.  Antitoxin  immunity  is  high  and  the  therapeutic  action  prompt 
in  proportion  to  the  amount  of  antitoxin  held  by  each  cubic  centimetre  of 
blood. 

INOCULATION    EXPERIMENTS. 

The  mouse,  rat,  rabbit,  guinea-pig,  and  dog  are  the  animals  usually 
selected  for  this  purpose.  Inoculations  are  made  either  with  pure  cultures, 
which  are  injected  by  means  of  a  sterilized  hypodermic  syringe,  or  infected 
tissues  are  implanted  under  strict  aseptic  precautions.  Injections  of  pure 
cultures  are  made  either  into  the  subcutaneous  tissue  or  one  of  the  large 
serous  cavities:  the  pleural  or  peritoneal  cavity.  The  same  localities  are 
generally  selected  for  inoculation  by  means  of  implantation  of  infected  tis- 
sue. For  instance,  granulation- tissue  from  tubercular  lesions  either  is  intro- 
duced into  a  small  pocket  made  in  the  subcutaneous  tissue  in  the  inguinal 
region  of  a  guinea-pig  or  a  small  fragment  is  inserted  into  the  pleural  or 
peritoneal  cavity  through  a  small  incision.  Before  the  incision  is  made  it 
is  absolutely  necessary  to  shave  the  surface  and  disinfect  it  in  the  usual  way. 
After  the  implantation  is  made  the  wound  is  closed  by  suturing  with  fine 
catgut,  after  which  it  is  sealed  with  coUodium.  In  the  course  of  two  or  three 
weeks  the  subcutaneous  graft  has  become  the  centre  of  a  local  tubercular 
fqcus,  which  soon  gives  rise  to  regional  infection  through  the  lymphatic  ves- 
sels, to  be  followed  at  the  end  of  five  or  six  weeks  by  general  diffuse  miliary 
tuberculosis.  In  cases  where  it  is  impossible  to  make  a  differential  diagnosis 
between  a  syphilitic  and  tubercular  lesion,  inoculation  of  a  guinea-pig  with 
a  fragment  of  the  granulation-tissue  will  furnish  positive  information  in 
the  course  of  a  few  Aveeks.  If  the  lesion  is  syphilitic,  the  result  of  the  in- 
oculation will  be  negative;  if  it  is  tubercular,  local,  regional,  and  general 
infection  will  follow  in  regular  order.  In  making  implantation  experiments 
from  animal  to  animal,  it  is  necessary  to  remove  the  graft  immediately,  or 
soon  after  death,  and  to  resort  to  the  necessary  precautions  to  prevent  con- 
tamination during  its  conveyance  from  the  dead  to  the  living  animal.  In 
bacterial  diseases  which  affect  the  blood,  inoculation  can  be  practiced  by 
injecting  blood,  abstracted  from  the  infected  animal,  into  the  subcutaneous 
tissue  or  general  circulation  of  a  healthy  animal,  with  the  effect  of  repro- 
ducing the  disease.  Anthrax  and  septicsemia  of  mice  furnish  good  illustra- 
tions of  this  class  of  infective  diseases. 

ATTENUATION    OF    PATHOGENIC    BACTERIA. 

Pasteur  opened  a  wide  field  for  investigation  in  preventive  medicine 
by  his  introduction  of  prophylactic  inoculations.     He  experimented  first 


168  PEINCIPLES    OF    SUEGERY. 

with  the  microbe  of  chicken-cholera  and  the  bacillus  of  anthrax.  The  mi- 
crobe of  fowl-cholera  was  cultivated  in  chicken  bouillon  for  three,  four,  five, 
or  eight  months.  He  found  that  by  that  time  the  virus  became  so  attenuated 
that,  when  injected  into  a  healthy  chicken,  it  killed  only  in  exceptional  cases. 
Experience  showed  that  attenuation  only  occurred  when  the  culture  was 
freely  exposed  to  atmospheric  air,  and  therefore  Pasteur  believed  that  the 
prolonged  contact  of  the  culture  with  oxygen  diminished  its  virulence. 
Chickens  inoculated  with  weak  cultures  were  rendered  immune  to  the  action 
of  the  active  virus.  The  same  author  made  the  discovery  that  the  anthrax 
bacillus,  cultivated  in  the  same  way  at  a  temperature  ranging  between  40° 
and  43°  C,  loses  its  virulence  gradually,  so  that  on  the  ninth  day  it  is  ren- 
dered harmless.  Inoculation  with  attenuated  cultures  protected  sheep 
against  the  active  virus.  Koch,  Gaffky,  and  Loffler  found  that  a  culture  of 
anthrax  bacilli  twenty  days  old,  attenuated  at  a  temperature  of  42°  to  46° 
C,  was  still  sufficiently  strong  to  kill  mice,  but  had  little  effect  on  guinea- 
pigs  and  sheep.  A  culture  twelve  days  old  killed  guinea-pigs,  but  not  sheep. 
It  proves  fatal  to  sheep  up  to  six  days  of  cultivation.  Their  views  in  refer- 
ence to  the  cause  of  attenuation  differ  from  Pasteur's,  who  regards  oxygen 
as  the  active  agent,  while  these  observers  attribute  it  exclusively  to  the  high 
temperature.  They,  like  Pasteur,  by  using  attenuated  cultures,  succeeded 
in  protecting,  in  most  cases,  sheep  against  the  action  of  virulent  cultures. 
In  his  practical  work  J'asteur  uses  two  strengths  of- mitigated  virus.  The 
milder  vaccine  is  a  culture  fifteen  to  twenty  days  old;  the  stronger  vaccine 
is  from  ten  to  twelve  days  old.  Sheep  are  inoculated  first  with  the  milder 
vaccine,  and  after  an  interval  of  twelve  to  fifteen  days  the  stronger  culture 
is  used.  Animals  thus  treated  are  either  entirely  immune  to  anthrax  or,  if 
they  contract  the  disease,  it  assumes  a  mild  type.  Other  methods  of  attenua- 
tion of  active  cultures  to  be  used  for  prophylactic  inoculations  have  been 
devised,  but,  as  they  appear  to  have  been  put  only  to  a  limited  extent  to 
practical  tests,  they  will  be  only  briefly  mentioned  here.  Sanderson  found 
that  the  bacillus  of  anthrax  loses  much  of  its  virulence  when  passed  through 
the  system  of  a  guinea-pig.  Toussaint  and  Chaveau  found  that  the  action 
of  a  temperature  of  from  50°  to  55°  C,  continued  for  five  to  twenty  minutes, 
greatly  diminishes  the  virulence  of  the  bacillus  of  anthrax.  For  the  attenua- 
tion of  spores  a  temperature  of  80°  C.  is  required. 

Paul  Bert  showed  that  oxygen,  under  a  pressure  of  from  20  to  40  centi- 
metres, destroys  the  bacillus  of  anthrax.  Toussaint,  Chamberland  and  Eoux, 
and  Klein  made  experiments  to  determine  the  influence  of  chemical  agents 
in  effecting  attenuation  of  active  cultures,  and  their  work  has  shown  that 
the  virulence  of  some  bacteria  can  be  greatly  diminished  and  even  entirely 
suspended  by  this  method  of  treatment.  Arloing  asserts  that  anthrax  bacilli, 
exposed  to  a  bright  sunlight  in  a  liquid  medium,  gradually  part  with  their 


THEKAPEUTIC  INOCULATION.  169 

toxic  qualities.  More  accurate  knowledge  and  greater  experience  in  this 
interesting  field  of  prophylactic  inoculations  will  undoubtedly  lead  to 
important  results  in  the  near  future. 

THEEAPEUTIC  INOCULATION. 

Therapeutic  inoculations  have  been  put  to  a  practical  test  upon  a  knowl- 
edge obtained  from  laboratory  work,  that  direct  antagonism  exists  among 
certain  kinds  of  microorganism's.  Emmerich's  experiments  on  rabbits  have 
demonstrated  the  value  of  the  streptococcus  of  erysipelas  as  a  protective  and 
curative  agent  in  anthrax  in  these  animals.  In  one  series  of  experiments 
the  rabbits  were  first  inoculated  with  a  large  quantity  of  a  reliable  culture 
of  the  microbe  of  erysipelas,  and  then,  two  to  fourteen  days  later,  the  ani- 
mals were  infected  with  a  pure  culture  of  the  anthrax  bacillus.  Of  15  ani- 
mals treated  in  this  way,  7  recovered,  while  all  the  control  animals  inoculated 
only  with  anthrax  died;  of  the  7  animals  which  died  after  double  infection, 
some  succumbed  to  the  anthrax  bacillus  and  some  to  the  streptococcus  of 
erysipelas.  Therapeutic  inoculations  with  cultures  of  the  microbe  of  ery- 
sipelas in  animals  suffering  from  anthrax  were  less  successful.  Garre  has 
studied  antagonism  among  bacteria  on  culture-soils.  He  made  many  careful 
experiments  to  determine  the  growth  of  a  culture  on  different  nutrient 
media,  by  removal  of  the  entire  culture  with  a  minute  spade  and  inoculation 
of  the  same  soil  with  another  microbe.  From  the  results  obtained  thus  far 
he  has  ascertained  that  some  microbes  affect  the  soil  favorably  for  the  growth 
of  other  varieties,  while  others  render  it  sterile.  For  example,  a  culture- 
medium  impregnated  with  the  ptomaines  of  the  bacillus  fluorescens  putidus 
remains  perfectly  sterile  when  inoculated  with  pus-microbes.  These  in- 
vestigations have  an  important  practical  bearing,  as  future  research  may  not 
only  show  the  way  to  secure  immunity  from  infection  by  pathogenic  microbes 
by  prophylactic  inoculations  with  harmless  microbes,  but  may  likewise  es- 
tablish a  system  of  rational  and  effective  treatment  by  inoculations  of  cult- 
ures of  antagonistic  bacteria  for  therapeutic  purposes.  Therapeutic  inocula- 
tions with  potent  cultures  have  also  been  made  with  some  success  in  the 
treatment  of  inoperable  malignant  tumors.  In  a  recent  publication  on  this 
subject  Bruns  gives  the  result  of  22  cases  of  malignant  growths,  including 
1  that  came  under  his  own  observation  that  passed  through  an  attack  of 
erysipelas.  Bruns'  case  was  one  of  melanosarcoma  of  the  breast,  in  which 
a  final  cure  followed  the  attack.  Out  of  5  sarcomata,  3  were  permanently 
cured,  while  the  other  2  were  diminished  in  size,  but  soon  returned  to  their 
former  size.  The  effect  of  the  erysipelatous  invasion  proved  negative  in  6 
cases,  in  which  the  diagnosis  between  carcinoma  and  sarcoma  could  not  be 
positively  made,  as  also  in  3  cases  of  ulcerating  epithelioma.     It  is  stated 


170  PRINCIPLES    OF    SUEGEEY. 

that  in  cicatricial  keloid  and  lympliomata  the  attack  of  erysipelas  proved 
curative. 

IMMUNITY. 

The  antiseptic  properties  of  blood-sernm  are  now  generally  recognized. 
These  properties  are  due  to  the  existence  of  a  substance  known  as  globulin,' 
and  upon  the  presence  of  this  substance  depends  the  natural  immunity  of 
certain  animals  and  persons  to  some  diseases  and  the  immunity  artificially 
produced  by  the  employment  of  serum  obtained  from  immune  animals  or 
injections  of  chemically-prepared  antitoxins.  Hankin  thus  defines  im- 
munity: "Immunity,  whether  natural  or  acquired,  is  due  to  the  presence  of 
substances  which  are  formed  by  the  metabolism  of  the  animal  rather  than 
that  of  the  microbe,  and  which  have  the  power  of  destroying  the  microbes 
against  which  immunity  is  possible  or  the  products  on  which  their  pathog- 
enic action  depends."  The  clinical  observations  relating  to  the  immunity 
acquired  after  an  attack  of  certain  acute  infectious  diseases  and  the  experi- 
mental evidences  which  have  accumulated  on  the  same  subject  tend  to  sup- 
port the  theory  that  acquired  immunity  depends  upon  the  formation  of 
antitoxins  in  the  bodies  of  immune  persons  and  animals  and  that  it  can  also 
be  produced  by  introducing  into  the  system  preformed  antitoxins.  As  sec- 
ondary factors,  it  is  probable  that  tolerance  to  the  toxic  products  of  pathog- 
enic microbes  and  phagocytosis  are  also  active,  but  to  a  lesser  extent. 

BACTEEIA    OUTSIDE    OP   THE    BODY. 

Bacteriology  has  rendered  the  term  miasma  obsolete.  All  infective  dis- 
eases are  now  traced  to  an  organic  contagium.  Most  of  the  bacteria  are 
edogenous;  that  is,  they  exist  and,  under  favorable  circumstances,  multiply 
outside  of  the  body.  The  microbe  of  syphilis,  in  all  probability,  is  an  endog- 
enous parasite.  Autoinfection  is  a  misapplied  term,  as  nearly  all,  if  not  all, 
infective  diseases  are  caused  by  the  introduction  into  the  body  of  pathogenic 
bacteria  from  without.  Some  microbes  exist  in  the  soil,  and  as  they  or  their 
spores  may  exist  in  an  active  condition  for  an  indefinite  period  of  time,  or 
even  germinate  there,  they  give  rise  to  endemics  and  epidemics  of  infective 
diseases.  The  anthrax  bacillus,  the  bacillus  of  tetanus,  and  the  actinomyces 
can  be  included  in  this  category.  Other  microbes  are  difl;used  over  large 
territories  through  water-courses,  as  the  bacillus  of  typhoid  fever  and 
cholera,  and  become  the  cause  of  epidemics  of  these  diseases.  Finally,  some 
bacteria,  like  pus-microbes,  appear  to  be  ubiquitous,  being  present  every- 
where and  at  all  times.  Of  all  substances  which  serve  as  a  carrier  of  mi- 
crobes, the  atmospheric  air  is  the  most  important,  because  it  is  present 
everywhere  on  the  surface  of  the  globe,  and  no  one  can  exclude  himself 
from  it.     In  a  dry  state,  pathogenic  bacteria  move  with  the  currents  of  air 


PEESENCE    OF    PATHOGENIC    BACTEEIA    IN    THE    HEALTHY   BODY.       171 

and  attach  themselves  again  to  the  solid  or  fluid  substances  with  which  they 
come  in  contact.  Although  most  of  the  pathogenic  bacteria  under  ordinary 
circimistances  do  not  reproduce  themselves  outside  the  body,  their  resistance 
to  heat  and  cold,  moisture  and  dryness,  is  so  great  that  they  retain  their 
disease-producing  qualities  often  for  an  indefinite  period  of  time,  and  after 
their  entrance  into  the  body,  and  meeting  with  a  proper  nutrient  medium, 
they  exert  their  specific  pathogenic  effects.  From  a  practical  stand-point 
it  is  important  to  rememher  that  infection  takes-  place  by  the  entrance  into  the 
tissues  or  body  of  microorganisms  from  without,  through  some  defect  of  the 
shin  or  mucous  membranes;  hence  by  contact  entrance  of  bacteria  into  the 
body  is  effected.  As  a  rule,  to  which  there  are  few  exceptions,  bacteria  are 
introduced  into  the  body  through  a  wound,  abrasion,  or  ulceration  of  the 
skin  or  a  mucous  membrane.  Such  a  defect  or  gateway  is  called  an  infection- 
atrium.  A  healthy,  granulating  surface  furnishes  almost  as  secure  a  pro- 
tection against  infection  as  the  skin,  but,  when  the  granulations  are  destroyed 
or  injured,  infection  is  again  liable  to  occur.  On  this  account  probing  of  a 
fistulous  canal  has  not  infrequently  resulted  in  aggravation  of  the  local 
symptoms,  and  even  in  general  infection.  Klister  reports  two  cases  where 
patients  who  had  undergone  an  operation  for  hydrocele  by  incision,  and 
who  were  permitted  to  leave  the  hospital  before  the  wound  had  completely 
healed,  died  subsequently  from  sepsis  caused  by  careless  after-treatment  of 
the  granulating  surface.  Most  of  the  microbes,  after  they  have  become 
deposited  upon  an  absorbing  surface,  exercise  first  their  pathogenic  qualities 
at  the  seat  of  primary  localization.  The  action  of  some  of  them  always  re- 
mains local.  If  the  infection  spread,  it  does  so  by  dissemination  of  the  mi- 
crobes over  a  surface,  along  the  connective  tissue,  or  through  the  lymphatics 
or  blood-vessels.  There  is  no  reason  to  doubt  that  bacteria  can  gain  entrance 
into  the  tissues  and  the  circulation  by  passing  through  intact  mucous  mem- 
branes in  the  same  manner  as  minute  particles  of  inorganic  material,  like 
coal-,  marble-,  and  ivory-  dust.     This  brings  up  the  question  of  the 

PEESENCE  OF  PATHOGENIC  BACTEEIA  IN  THE  HEALTHY  BODY. 

It  still  remains  a  disputed  question  whether  pathogenic  microorganisms 
can  exist  in  the  body  without  giving  rise  to  disease.  It  has  been  definitely 
ascertained,  by  experimental  research,  that  many  of  the  pathogenic  microbes 
are  harmless  so  long  as  they  remain  in  the  circulating  blood,  and  that  their 
specific  pathogenic  action  only  becomes  evident  after  localization  has  taken 
place  in  some  part  of  the  body,  in  a  soil  prepared  by  injury  or  disease  for 
their  reproduction.  It  has  also  been  conclusively  shown,  by  clinical  experi- 
ence, that  pathogenic  spores  may  remain  in  the  healthy  body,  in  a  dormant 
condition,  for  an  indefinite  period  of  time,  until,  by  some  accidental  patho- 
logical changes,  the  tissues  in  Avhich  they  may  exist  have  been  prepared  for 


172  PKINOIPLES    OF    SUEGERY. 

their  germination.  Numerous  experiments -will  be  cited  elsewhere,  in  which 
injections  of  pure  cultures  directly  into  the  circulation  produced  no  ill 
effects  in  healthy  animals,  but  when,  previous  to  the  injection  or  soon  after, 
an  injury  was  inflicted  in  some  part  of  the  body,  localization  occurred  at  the 
seat  of  trauma,  and  in  the  locus  minoris-  resistentice  thus  created  the  microbes 
produced  their  specific  pathogenic  effects.  From  these  remarks  it  is  reason- 
able to  assume  that  pathogenic  microbes  may  and  do  exist  in  the  healthy  tody 
without  necessarily  giving  rise  to  disease,  especially  if,  as  is  well  hnoivn,  they 
are  leing  constantly  eliminated  through  the  excretory  organs. 

Bizzozero  could  not  detect  bacteria  of  any  kind  in  animals  soon  after 
birth,  but  in  the  lymph-follicles  of  the  caecum  in  healthy  rabbits  he  found 
numerous  microorganisms.  They  were  seen  mostly  in  the  protoplasm  of 
cells:  a  condition  which  would  indicate  that  they  are  transferred  from  the 
intestinal  canal  into  the  closed  lymph-follicle  through  the  mediujn  of  mi- 
grating cells.  In  the  human  subject  Eibbert  found  microorganisms  in  the 
interior  of  the  epithelia  lining  the  intestinal  canal,  but  they  were  absent  in 
the  submucosa.  Perhaps  the  epithelial  cells  in  this  locality  take  the  part  of 
phagocytes.  Kalbe  found  that  in  the  larger  majority  of  cases  the  peribron- 
chial glands  of  hogs  contain  bacteria  such  as  the  pus-microbes,  the  bacillus 
capsulatus,  and  micrococcus  lanceolatus,  demonstrable  by  cultural  methods. 
In  two  of  twenty-three  non-tubercular  human  bodies,  dying  from  acute  in- 
fectious diseases  or  accidents  he  found  tubercle  bacilli  in  these  glands. 
While  it  seems  reasonable  to  assume  that  the  peribronchial  glands  exercise 
some  antibacterial  influence  upon  the  bacteria  they  frequently  retain,  it 
should  also  be  noted  that  these  glands  might  become  the  infection-atrium 
of  organisms  giving  rise  to  cryptogenetic  infections.  The  common  sapro- 
phyte proteus  vulgaris  was  found  to  be  pathogenic  for  rabbits  when  injected 
into  the  dorsal  muscles  in  sufficient  numbers.  But,  according  to  the  esti- 
mates made,  225,000,000  were  required  to  cause  death,  while,  with  doses  of 
from  9,000,000  to  112,000,000,  a  local  abscess  was  produced,  and  less  than 
9,000,000  gave  an  entirely  negative  result.  Watson-Cheyne  found,  in  his 
experiments  made  for  the  purpose  of  ascertaining  the  presence  of  microor- 
ganisms in  the  living  tissues,  that,  while  they  were  not  present  when  the 
animal  was  in  good  condition,  yet,  if  the  vitality  of  the  animal  was  de- 
pressed, say,  by  administering  large  doses  of  phosphorus  for  some  time,  mi- 
crobes could  be  found,  at  times,  in  the  blood  and  tissues  of  the  body.  Again, 
it  has  been  found  that,  while  some  microorganisms,  when  introduced  into 
the  living  body  in  small  number,  disappear  after  a  short  time,  when  a  large 
quantity  of  the  culture  is  introduced  the  tissues  of  the  body  are  injured  by 
the  preexisting  toxins,  and  the  microbes  retain  their  vitality  and  often 
cause  inflammation  of  the  organ  in  which  they  locate.  The  conditions,  then, 
upon  which  depend  the  preservation  of  health,  in  the  event  of  the  entrance 


LOCALIZATION    OF   BACTERIA.  173 

of  pathogenic  microbes  into  the  body,  are:  1.  The  number  of  microbes  in- 
troduced. 3.  Absence  of  a  locus  minoris  resisteniice.  3.  Active  elimination 
through  the  excretory  organs. 

LOCALIZATION"    OF    BACTERIA. 

Every  surgeon  has  had  frequent  opportunities  to  observe  cases  in  which 
a  slight  subcutaneous  injury  was  followed  by  a  destructive  inflammation:  an 
inflammation  not  caused  by  the  trauma  alone,  but  by  the  trauma  giving  rise 
to  localization  of  pathogenic  microbes  in  the  tissues  altered  by  the  injury. 
Thus,  Chaveau  has  shown  experimentally  that  a  subcutaneous  contusion  fur- 
nishes an  excellent  condition  for  the  localization  of  pathogenic  bacteria  car- 
ried to  the  part  by  the  circulating  blood.  When  he  injected  a  putrid  fluid 
directly  into  the  circulation  of  young  rams  shortly  before  crushing  subcu- 
taneously  one  of  the  testicles,  the  injured  organ  always  became  the  seat  of 
septic  gangrene,  while  without  such  injection  the  testicle  disappeared  com- 
pletely by  necrobiosis  and  absorption.  Gangrene  only  occurred  if  the  putrid 
fluid  contained  bacteria;  it  did  not  take  place  when  the  injected  fluid  had 
been  sterilized  by  filtration.  Extensive  subcutaneous  injuries — as  severe 
contusions,  rupture  of  tendons  or  muscles,  and  comminuted  fractures — are 
not  followed  by  suppuration  unless  the  injured  tissues  become  subsequently 
the  seat  of  infection  with  pus-microbes.  A  patient  may  have  been  the  sub- 
ject of  tubercular  infection  for  an  indefinite  period  of  time,  and  yet  may 
present  the  appearances  of  ordinary  health,  until  some  slight  injury  deter- 
mines localization  of  the  bacillus  in  the  part  injured:  an  occurrence  which 
is  followed  by  a  localized  tuberculosis  from  which,  later,  regional  and  gen- 
eral dissemination  takes  place,  to  which  the  patient  finally  succumbs,  unless 
the  tubercular  focus  is  removed  by  an  early  operation.  These  facts  suggest 
very  strongly  that,  in  the  hypothetical  cases,  suppuration  and  tuberculosis 
would  not  have  occurred  in  the  part  injured  without  the  injury,  and  that  the 
injury  certainly  ivould  not  have  produced  suppuration  or  tuberculosis  unless 
the  respective  patients  have  been  infected  previously  with  the  specific  microor- 
ganisms. The  injury  in  these  cases  created  a  so-called  locus  minoris  resisten- 
tice,  which  may  signify  one  of  two  things:  (1)  diminution  or  suspension  of 
the  vital  resistance  on  the  part  of  the  injured  tissues  to  the  action  of  pathog- 
enic microbes;  or  (2)  the  injury  so  alters  the  tissues  that  bacteria,  which  were 
present  in  the  circulation  without  having  given  rise  to  symptoms,  become 
arrested  and  find  at  the  same  time,  at  the  seat  of  localization,  the  necessary 
conditions  for  their  reproduction.  Huber  studied  experimentally  the  effect 
of  chemical  irritation  of  tissues  in  determining  localization  of  the  bacillus 
of  anthrax.  The  experiments  were  made  on  rabbits,  in  which,  by  the  ex- 
ternal application  of  croton-oil  to  the  ear,  he  produced  ^a  tissue-lesion  by  the 
inflammation  which  followed.     Que  ear  was  thus  treated,  the  other  being 


174  PKINCIPLES    OF    SURGEEY. 

left  in  a  normal  condition  in  order  to  compare  the  results  of  localization  of 
anthrax  bacilli  in  inflamed  and  normal  vessels.  As  soon  as  the  inflammation 
was  established,  a  pure  culture  of  anthrax  bacilli  was  inserted  subcutaneously 
at  the  root  of  the  tail;  this  place  was  selected  in  order  to  make  the  infection 
as  distant  as  possible  from  the  inflamed  ear.  In  some  cases  the  croton-oil 
was  applied  after  the  inoculation.  Immediately  after  the  death  of  the  ani- 
mal, both  ears  were  cut  oif  and  carefully  preserved  for  subsequent  examina- 
tion, and,  at  the  same  time,  serum  and  blood  were  separately  taken  from  the 
inflamed  ear  and  preserved  in  sterilized  glass  tubes. 

The  results  of  a  number  of  these  experiments  enabled  the  author  to 
assert  that  in  all  stages  of  the  inflammation  the  bacilli  were  never  found  out- 
side the  walls  of  the  capillary  blood-vessels  in  the  crotonized  ear.  Their 
number  within  the  blood-vessels  depended  upon  the  condition  of  the  in- 
flamed vessels.  During  the  first  stage  of  inflammation,  marked  by  oedema 
without  suppuration,  more  bacilli  were  found  within  the  inflamed  vessels 
than  in  the  corresponding  vessels  of  the  opposite  ear.  During  the  suppura- 
tive stage  the  bacilli  disappeared  from  the  vessels.  During  the  third  stage, 
when  granulations  commenced  to  form,  a  complete  change  was  again  ob- 
served in  the  bacteriological  condition  of  the  inflamed  part.  The  height  of 
this  stage  is  reached  on  the  tenth  day.  During  this  stage  the  bacilli  reap- 
peared in  the  inflamed  tissue,  where  they  could  be  seen  in  considerable  num- 
ber, especially  in  the  interior  of  new  capillary  vessels.  During  cicatrization 
the  number  of  bacilli  in  a  corresponding  area  of  both  ears  was  about  the 
same. 

From  these  observations  the  author  concludes  that  the  bacillus  of 
anthrax  finds,  in  a  soil  prepared  by  inflammation  induced  with  croton-oil, 
a  locus  minoris  resistentice  which  presents  more  favorable  conditions  for  its 
localization  and  growth  than  the  tissues  in  other  parts  of  the  body.  Sup- 
puration appeared  to  neutralize  the  anthracic  process  by  the  destructive 
effect  of  the  pus-toxins  upon  the  bacilli. 

The  conclusions  which  he  has  drawn  from  his  experiments  may  be  sum- 
marized as  follows:  Localization  of  preexisting  microorganisms  in  tissues 
prepared  by  injury  or  disease  takes  place,  provided  that  the  necessary  condi- 
tions for  their  growth  are  present.  In  looking  over  different  pathological 
conditions  we  frequently  meet  with  a  so-called  locus  minoris  resistentice;  at 
any  rate,  if  we  search  only  for  that  which  should  mean  what  has  been  de- 
scribed above,  it  is  not  difficult  to  conceive  how  slight  injuries,  wounds, 
contusions,  etc.,  should  in  this  manner  give  rise  to  serious  affections.  But 
not  only  do  direct  tissue-lesions,  as  hgemorrhage,  necrosis,  hyperemia,  fract- 
ures, etc.,  act  in  this  manner,  but  a  variety  of  pathological  conditions  of  a 
general  nature  may  siprve  the  same  purpose,  as  imperfect  digestion,  enfeebled 
circulation  and  respiration,  and  particularly  irregular  distribution  of  blood 


LOCALIZATION    OF    BACTEKIA.  175 

resulting  from  exposure  to  cold.  All  these  ill-defined  conditions  belong  here, 
and  through  their  instrumentalities  the  localization  of  infective  microbes 
is  favored.  In  secondary  or  mixed  infection  the  microbes  which  exist  in  the 
tissues  first  prepare  the  soil  for  the  arrest  and  germination  of  other  bacteria 
which  may  reach  the  circulation. 

Muskatbliith  studied  experimentally  the  fate  of  anthrax  bacilli  when 
introduced  directly  into  the  trachea  by  injection  through  the  larynx,  or 
through  a  tracheotomy  wound.  From  the  results  which  he  obtained  he  con- 
cludes that  the  bacilli  can  enter  the  circulation  through  the  bronchial  mu- 
cous membrane,  and  that  the  Juice-canals  and  lymphatics  are  the  channels 
through  which  the  infection  takes  place.  It  appeared  strange  to  the  author 
that  no  bacilli  could  be  found  in  leucocytes,  but  always  only  in  epithelial 
cells.  Final  localization  of  the  bacilli  which  have  entered  the  circulation 
through  the  lungs  takes  place  in  distant  organs  by  implantation  upon  the 
endothelial  lining  of  the  capillary  vessels. 

Other  experimenters  affirm  that  if  the  anthrax  bacilli  are  injected  in 
moderate  quantities  into  the  circulation  of  animals,  they  disappear  soon  from 
the  blood  without  having  produced  any  pathogenic  effects;  but,  if  in  ani- 
mals thus  infected  a  contusion  is  produced  in  some  part  of  the  body,  the 
bacilli  pass  out  of  the  injured  vessels  into  the  connective  tissue  along  with 
the  blood,  germinate  there,  and  soon  cause  the  formation  of  the  character- 
istic inflammatory  product,  the  disease  becomes  diffused,  and  the  animals 
die  of  anthrax.  Localization  of  the  bacillus  of  tuberculosis  affords  an  in- 
teresting subject  for  further  experimental  research  and  clinical  study. 

The  late  distinguished  Professor  von  Volkmann,  from  an  extensive  clin- 
ical experience,  came  long  ago  to  the  important  and  practical  conclusion  that 
a  severe  trauma  seldom,  if  ever,  gives  rise  to  tuberculosis  at  the  seat  of  in- 
jury; and,  on  the  other  hand,  that  in  cases  where  tuberculosis  develops  in 
consequence  of  any  injury,  the  trauma  is  always  slight,  sometimes  almost 
insignificant.  The  experience  of  almost  every  surgeon  will  agree  with  these 
statements.  Volkmann  maintains  that  the  active  tissue  changes  which  fol- 
low a  severe  trauma  during  the  reparative  process  counteract  the  groAvth 
.  and  propagation  of  the  bacillus.  Luecke  attributes  to  exposure  to  cold  an 
important  role  in  the  causation  of  tubercular  and  other  infective  forms  of 
inflammation,  as  he  asserts  that  the  sudden  diminution  of  blood-supply  to 
the  cutaneous  surface  causes  internal  congestions,  which  favor  the  localiza- 
tion of  pathogenic  microbes  in  some  one  of  the  congested  organs,  otherwise 
predisposed  to  the  specific  inflammation.  Schliller  studied  the  localization 
of  the  tubercular  virus  experimentally  in  the  same  manner  as  others  have 
studied  the  localization  of  pus-microbes.  He  inoculated  animals  with  the 
products  of  tubercular  inflammation,  subsequently  produced  contusions  and 
sprains  of  joints,  and  observed  that  localization  usually  occurred  at  the  seat 


176  PRINCIPLES    OF    SURGERY. 

of  injury.  If  the  tubercular  virus  was  introduced  by  inhalation,  the  same 
typical  lesions  occurred  in  the  injured  joints  as  when  infection  was  practiced 
in  a  more  direct  manner.  In  all  cases  the  product  of  the  local  joint-lesion 
corresponded  with  the  character  of  the  material  introduced  through  some 
remote  point.  Surgeons  are  well  aware  of  the  danger  of  general  infection 
following  an  injury  to  a  part  or  an  organ  the  seat  of  local  tuberculosis,  more 
particularly  in  cases  of  tubercular  disease  of  joints  treated  by  brisement  force. 
Numerous  cases  are  recorded  where  this  procedure  was  followed  within  a 
few  days  by  general  miliary  tuberculosis  and  a  speedy  death.  In  all  cases 
where  a  local  tuberculosis  develops  in  consequence  of  an  injury,  we  must 
take  it  for  granted  that  the  injured  part  contained  the  essential  cause  of  the 
disease,  the  bacillus  of  Koch,  and  that  the  lesions  caused  by  the  trauma 
created  the  necessary  conditions  for  its  reproduction;  or,  if  the  injured  tis- 
sues at  the  time  are  sterile,  that  they  serve  the  purpose  of  a  locus  minoris 
resistentice  for  bacilli  which  might  reach  them  through  the  circulation.  The 
frequency  with  which  suppuration  occurs  without  any  visible  infection- 
atrium  has  led  bacteriologists  to  investigate  with  special  care  and  diligence 
the  localization  of  pus-microbes. 

Eosenbach  ascertained,  by  numerous  experiments,  that  acute  suppura- 
tive osteomyelitis  could  only  be  produced  by  injecting  pus-microbes  directly 
into  the  circulation  and  by  injuring  the  medullary  tissue  a  few  days  before 
or  after  the  inoculation.  Kocher,  Becker,  and  Krause  repeated  the  experi- 
ments of  Eosenbach,  and  came  essentially  to  the  same  conclusions.  Both 
Kocher  and  Eosenbach  look  upon  the  altered  circulation  in  the  injured  part 
as  the  essential  condition  which  determines  localization  of  the  pus-microbes 
floating  in  the  blood-current;  at  the  same  time,  they  admit  that  the  imme- 
diate tissue-lesions — haemorrhage  and  necrosis — may  have  the  same  effect. 
Upon  the  same  theory,  Kocher  explains  the  occurrence  of  traumatic  sup- 
purative strumitis  in  an  hyperplastic  struma.  If  non-septic  pus  is  injected 
into  the  circulation  of  healthy  animals  in  moderate  quantities,  no  serious  re- 
sults are  produced,  as  the  pus-microbes  are  soon  eliminated  through  the 
kidneys.  If,  however,  the  pus-microbes  attach  themselves  in  the  circulation 
to  some  foreign  substance  which  prevents  such  elimination,  suppuration  will 
follow.  A  number  of  experiments  made,  among  others  by  Eibbert,  on  the 
production  of  myocarditis  and  endocarditis  in  rabbits,  have  shown  that  ab- 
scesses can  be  produced  in  other  organs  if  the  pyogenic  microbes  are  attached 
to  foreign  bodies  which  cannot  pass  through  the  pulmonary  capillaries. 
Thus,  Eibbert  was  able  to  produce  myocarditis  by  using  a  cultivation  of 
staphylococcus  pyogenes  aureus  on  potato,  if  he  took  the  precaution,  in  re- 
moving the  culture  from  the  surface  of  the  potato,  to  scrape  off  also  the 
superficial  surface  of  the  potato  itself.  The  particles  of  potato  injected  with 
the  microbes  determined  suppuration  by  causing  localization  of  the  microbes, 


LOCALIZATION    OF    BACTERIA.  177 

as  the  foreign  bodies  were  too  large  to  pass  tlirough  the  capillary  vessels  and 
were  not  capable  of  removal  by  absorption. 

The  influence  of  a  trauma  in  determining  localization  of  microbes  cir- 
culating in  the  blood  is  well  shown  by  the  experiments  which  have  been 
made  to  produce,  artificiall}^,  endocarditis  in  animals.  0.  Kosenbach  made 
the  first  experiments  of  this  kind.  He  observed,  in  his  experiments  on  ani- 
mals and  in  post-mortem  examinations  in  cases  of  ulcerative  endocarditis, 
microbic  emboli  in  the  valves  of  the  heart  and  in  the  infarcts  of  other  organs, 
and  classifies  this  affection  with  pygemia.  The  more  frequent  occurrence  of 
endocarditis  in  the  left  side  of  the  heart  than  the  right  he  explains  by  as- 
suming that  the  microbes  find  a  better  soil  in  the  arterial  blood,  as  when  the 
affection  occurs  in  the  foetus  during  intrauterine  life,  when  the  blood  in  both 
sides  of  the  heart  is  of  about  the  same  composition,  the  valves  in  both  sides 
are  affected  with  the  same  frequency.  Orth  and  Wyssokowitsch  found  that 
staphylococci  could  be  injected  into  the  blood  of  a  rabbit  without  apparent 
injury  to  it,  but  if  before  the  injection  a  slight  mechanical  injury  was  in- 
flicted on  one  of  the  valves  of  the  heart,  typical  endocarditis  was  at  once 
produced.  The  injury  was  produced  with  a  small  rod,  which  was  introduced 
into  the  jugular  vein  on  the  right  side.  The  endocardial  lesion  always  cor- 
responded to  the  seat  of  the  injury.  Similar  results  were  obtained  by 
Frankel  and  Sanger. 

Einne  came  to  different  conclusions  in  reference  to  injured  tissues  serv- 
ing as  a  locus  minoris  resistentice  in  the  causation  of  inflammation  due  to  the 
presence  of  microbes.  He  injected  pure  cultures  of  the  different  kinds  of 
pus-microbes  directly  into  the  circulation  of  animals,  and  found  that,  as  a 
rule,  no  harm  resulted.  In  rabbits  he  injected  from  2  to  3  Pravaz  syringefuls 
of  unfiltered,  distilled  water,  holding  in  suspension  pure  cultures,  and,  after 
repeating  this  dose  several  times,  inflicted  all  kinds  of  subcutaneous  lesions 
without  causing  suppuration.  Only  in  a  few  instances  were  pyemic  metas- 
tases observed,  and  these  occurred  usually  only  in  cases  where  undiluted 
gelatin  cultures  were  used.  In  several  dogs  he  made  subcutaneous  fractures 
and  then  injected  large  doses  of  cultures  of  pus-microbes,  suspended  in  dis--. 
tilled  water,  into  the  peritoneal  cavity,  but  no  suppuration  occurred  at  the 
seat  of  trauma.  In  six  rabbits  he  fractured  the  femur  subcutaneously  and 
then  injected  pure  cultures  into  the  jugular,  or  one  of  the  auricular,  veins, 
but  only  in  one  of  them  did  osteomyelitis  occur  at  the  seat  of  fracture.  In 
two  experiments  where  he  injected  osteomyelitic  pus  diluted  with  distilled 
water  the  seat  of  fracture  suppurated,  and  in  these  cases  abscesses  were  also 
found  in  the  heart-muscle  and  the  kidneys  at  the  autopsy.  It  is  difficult  to 
explain  the  discrepancy  between  the  results  obtained  by  Einne  and  the  other 
experimenters  who  have  been  quoted,  as  the  same  kind  of  animals  and  in- 
oculation material  were  used,  and  the  experiments  Avere  conducted  in  the 


178  PEINCIPLES    OF    SUEGERT. 

same  manner.  Tlie  fad  remains,  and  is  abundantly  vouched  for  by  clinical 
experience,  that  a  subcutaneous  injury,  if  the  tissues  remain  sterile,  does  not 
give  rise  to  inflammation,  and  that  many  inflammatory  processes  are  estab- 
lished immediately  or  soon  after  an  injury,  and  in-  the  inflammatory  product 
the  presence  of  pathogenic  bacteria  can  be  demonstrated  by  microscopical  ex- 
amination, cultivation,  and  inoculation  experiments.  A  number  of  well- 
authenticated  cases  of  osteomyelitis  after  simple  subcutaneous  fraqture  have 
been  recorded  wher€  the  infection  could  be  traced  to  a  slight  peripheral  sup- 
purative lesion.  The  same  can  be  said  of  many  cases  of  suppurative  osteo- 
myelitis which  occur  without  fracture,  where  the  exciting  cause  can  be  re- 
ferred to  some  slight  injury,  or  exposure  tO'  cold,  and  the  essential  cause  can 
be  located  in  some  pus-producing  lesion  in  a  distant  part,  and  having  no 
direct  vascular  connections  with  the  suppurating  medullary  tissue.  From 
a  scientific  and  practical  stand-point,  it  is  important  to  recognize  the  ex- 
istence of  local  conditions  in  the  tissues  created  by  a  trauma,  or  antecedent 
pathological  conditions,  to  explain  the  localization  of  floating  microbes  and 
the  production  of  local  affections  by  their  uniform  presence  and  constant 
patliogenic  action. 

SECOXDAET,    OE    MIXED,    IXFECTIOX. 

Antecedent  pathological  products  may  serve  the  same  purpose  in  the 
body  as  a  trauma  in  the  determination  of  localization  of  pathogenic  microbes. 
Suppuration  in  a  tumor,  or  an  hyperplastic  gland  with  an  intact  cutaneous 
covering,  indicates  that  in  the  tumor  or  swelling  pus-microbes  have  been 
arrested,  and  that  they  have  been  deposited  in  a  soil  adapted  to  their  ger- 
mination and  the  exercise  of  their  pathogenic  qualities.  The  atypical  vas- 
cularization in  tumors  and  the  partial  obstruction  in  the  lumen  of  blood- 
vessels in  inflammatory  swellings  cannot  fail  in  creating  conditions  which 
determine  filtration  of  bacteria-containing  blood.  If  the  preexisting  patho- 
logical product  is  the  result  of  a  previous  infection,  and  serves  as  a  medium 
for  localization  of  another  kind  of  pathogenic  microbes,  we  speak  of  the  com- 
bined process  due  to  the  presence  of  two  varieties  of  microorganisms  as  a 
mixed  infection.  The  first  positive  proof  of  the  existence  of  a  secondary  or 
mixed  infection  was  furnished  by  Brieger  and  Ehrlich.  These  observers  saw 
a  malignant  oedema  develop  at  the  point  where  musk  was  injected  hypoder- 
mically  in  a  severe  case  of  typhoid  fever.  They  found  that  in  such  cases  a 
predisposition  is  established  by  an  existing  disease  to  the  growth  and  repro- 
duction of  microorganisms,  which  may  have  been  previously  present  in  the 
organism  without  producing  any  pathological  lesions. 

Koch,  in  his  article  on  "The  Etiology  of  Tuberculosis,"  alludes  to  the 
occurrence  of  mixed  infection,  as  he  states  that  he  saw  at  the  same  time 
bacilli  and  micrococci  present  in  the  same  tubercular  lesion.     In  reference 


SECONDARY,    OR   MIXED,    INFECTION.  179 

to  the  occurrence  of  micrococci  in  tubercular  deposits  in  the  lungs  and 
spleen,  he  explained  their  presence  upon  the  supposition  that  they  entered 
the  circulation  through  ulcerations  of  the  tongue,  and  that  they  became 
arrested  in  the  capillary  vessels,  which  had  lost  their  normal  resisting  power 
by  the  tribercular  process.  Bumm  maintains  that  in  some  patients  secondary 
infection  is  a  purely  accidental  occurrence,  as,  for  example,  a  tubercular 
patient  can  be  attacked  with  erysipelas;  a  lying-in  woman  suffering  from 
gonorrhoea  may  become  the  subject  of  septic  infection. 

Another  and  practically  more  important  yariety  of  mixed  infection  he 
speaks  of  where  a  more  direct  relation  exists  between  the  different  microbes,  in 
the  sense  that  the  one  precedes  the  other  and  prepares  the  soil  for  the  growth 
of  the  latter.  These  forms  are  characterized  by  being  constantly  associated 
with  certain  definite  microbes.  The  pneumococcus  may  prepare  the  soil  for 
fructification  of  the  bacillus  of  tuberculosis  or  the  microbes  of  suppuration 
in  individuals  that  otherwise  would  have  been  immune  to  the  action  of  these 
microorganisms.  The  gonococcus  can  also  modify  the  mucous  membrane 
of  the  genito-urinary  tract  in  such  a  manner  as  to  render  easy  the  invasion 
of  other  pathogenic  microbes.  Gonorrhoeal  infection  of  the  vulvo-vaginal 
gland  furnishes  a  good  illustration.  As  long  as  the  infection  remains  purely 
gonorrhceal,  the  acute  suppurative  stage  is  followed  by  a  chronic  stage  which 
may  last  for  several  months,  the  swelling  gradually  subsides,  and  subse- 
quently atrophy  and  sclerosis  of  the  gland  follow.  If,  however,  pyogenic 
infection  is  added  to  the  gonorrhoea,  the  gland  soon  becomes  enlarged  and 
tender,  and  suppuration  follows.  In  the  abscess  and  its  vicinity  no  gonococci 
can  be  found;  the  pus  only  contains  pyogenic  microbes,  which  exterminated 
the  gonococci.  Cystitis  which  accompanies  gonorrhoea  is,  again,  a  variety 
of  mixed  infection.  The  stratified  epithelium  of  the  bladder  is  impenetrable 
to  the  gonococcus. 

According  to  Bumm,  the  cystitis  is  maintained  by  another  species  of 
microbe  resembling  the  gonococcus,  but  differing  from  it  by  taking  a  dif- 
ferent staining.  The  gonococcus  expends  its  action  on  the  superficial  layers 
of  the  mucous  membrane  exclusively.  Suppurative  parametritis  following 
gonorrhoea  is  analogous  to  a  gonorrhoeal  bubo,  which  is  always  caused  by  a 
secondary  infection  with  pus-microbes.  A  valuable  contribution  to  our 
knowledge  of  mixed  infection  has  recently  been  made  by  Babes.  His  in- 
vestigations consist  of  a  series  of  bacteriological  studies  of  the  tissues  of  chil- 
dren who  died  of  infectious  diseases.  Within  a  few  hours  after  death  frag- 
ments of  tissue  were  removed  from  different  organs  which,  under  strict  anti- 
septic precautions,  were  imbedded  in  sterilized  culture-material.  In  acute 
infectious  diseases,  such  as  diphtheria  and  scarlatina,  cultures  from  the 
spleen,  kidneys,  liver,  lungs,  and  blood  yielded  numerous  colonies  of  strep- 
tococci, putrefactive  bacteria,  capsule  cocci,  more  rarely  staphylococci  and 


180  PKINCIPLES    OF    SURGERY. 

various  bacilli.  Of  special  interest  are  his  researches  on  the  manner  of  local- 
ization and  'extension  of  the  secondary  invasion  after  different  primary  dis- 
eases. In  8  cadavers  he  found  one  or  more  species  of  bacteria  in  the  internal 
organs.  In  a  case  of  septic  omphalitis  he  found  the  bacillus  of  green  pus. 
In  6  cases  of  different  forms  of  infectious  disease  the  streptococcus  pyogenes 
could  be  cultivated  from  the  tissues,  and  only  in  1  was  the  yellow  pus-mi- 
crobe present  in  the  culture.  Various  putrefactive  bacilli  were  cultivated 
from  5  cases.  In  some  instances  he  was  able  to  demonstrate  the  point  at 
which  the  different  secondary  invasions  had  taken  place.  Thus,  in  a  case 
of  sepsis  after  scarlatina,  in  which  streptococci  were  found  in  every  part 
of  the  body,  a  streptococcus  pneumonise  was  found  in  the  lower  portion  of 
the  left  lung,  while  a  number  of  foci  in  the  upper  portion  of  the  opposite 
lung  contained  only  bacilli. 

Frankel  and  Freudenberg  cultivated  from  internal  organs  of  3  patients 
who  had  died  of  scarlatina  the  streptococcus  pyogenes,  and  they  maintain 
that  the  presence  of  this  microbe  is  evidence  that  a  secondary  infection  takes 
place  through  the  diseased  mucous  membrane  of  the  pharynx. 

Schnitzler,  after  having  observed  and  carefully  studied  a  number  of 
cases,  has  come  to  the  conclusion  that  syphilitic  ulcerations  of  the  larynx 
may  pass  into  tubercular,  as  the  syphilitic  ulcer  furnishes  a  good  culture- 
soil  for  the  bacillus  of  tuberculosis. 

Huber  attributes  the  occurrence  of  suppuration  and  gangrene  in  croup- 
ous pneumonia,  phlegmonous  inflammation  and  suppuration  in  erysipelas, 
and  suppuration  in  tubercular  processes  to  secondary  infection  with  pus- 
microbes.  As  the  bacillus  of  tuberculosis  and  the  streptococcus  of  erysipelas 
do  not  possess  the  property  of  converting  leucocytes  and  embryonal  cells 
into  pus-corpuscles,  suppuration,  if  it  does  occur  in  these  diseases,  can  only 
be  accounted  for  by  admitting  the  existence  of  a  secondary  infection  with 
pus-microbes. 

The  important  question  presents  itself  whether,  in  cases  of  mixed  in- 
fection, the  two  or  more  kinds  of  microbes  enter  the  organism  at  the  same 
time,  or  whether  primary  infection  prepares  the  way  for  the  entrance  and 
fructification  of  the  microbes  which  produce  the  secondary  infection.  Pus- 
microbes  being  present  at  all  times  and  everywhere,  and  perhaps  gaining 
entrance  into  the  body  more  readily  than  others,  it  is  very  easy  to  under- 
stand why  secondary  infection  by  them  is  most  frequently  observed.  Eosen- 
bach  frequently  found  in  pus  more  than  one  kind  of  pyogenic  microbes. 
He  often  cultivated  from  the  same  pus  two  kinds  of  staphylococci,  or  one 
variety  of  staphylococci  with  streptococci.  While  antagonism  among  some 
bacteria  has  been  shown  to  exist,  others  prepare  the  soil  for  the  growth  of 
a  different  variety,  and  in  such  instances  it  is  not  difficult  to  conceive  that 
secondary  infection  is  of  frequent  occurrence.     For  instance,  any  microbe 


ELIMINATION    OF    PATHOGENIC    BACTEEIA.  181 

that  will  convert  mature  tissue  into  embryonal  cells  abbreviates  and  lightens 
the  work  of  pus-microbes  in  converting  iixed  tissue-cells  into  pus-corpuscles. 

ELIMINATION    OF    PATHOGENIC    BACTEEIA. 

Having  described  the  different  ways  in  which  pathogenic  bacteria  enter 
the  body,  it  now  remains  to  show  in  what  manner  they  are  disposed  of  in  the 
event  no  harm  follows  or  the  patient  recovers  from  the  disease  which  they 
produced.  The  probable  existence  of  disease-producing  microorganisms  in 
the  healthy  body  and  the  spontaneous  subsidence  of  many  infective  processes 
make  it  important  to  consider  the  ways  and  means  by  which  they  are  ren- 
dered harmless  in  the  living  body,  or  are  removed  by  elimination  through 
some  of  the  excretory  organs.  In  all  infective  processes  in  which  life  is  not 
destroyed,  and  the  products  of  inflammation  do  not  find  their  way  to  the 
surface  spontaneously  or  by  operative  treatment,  the  microbes  are  either  de- 
stroyed in  the  blood  and  the  tissues  by  |)hagocytosis  or  are  eliminated 
through  some  of  the  excretory  organs  in  an  active  state.  The  rapid  disap- 
pearance of  most  microbes  from  the  blood  when  injected  into  the  circulation 
of  healthy  animals  would  indicate  that  an  active  warfare  is  instituted  against 
them  by  the  colored  corpuscles  of  the  blood,  in  which  the  microbes  are  de- 
feated; that  is,  destroyed.  If  some  of  the  microbes  pass  through  the  capil- 
lary blood-vessels  and  come  in  direct  contact  with  the  fixed  tissue-cells,  a 
similar  struggle  ensues  between  them  and  the  tissue-cells,  and  if  the  latter 
are  victorious  the  microbes  are  destroyed.  Successful  phagocytosis  must 
therefore  be  considered  as  the  most  efficient  and  desirable  way  of  disposing 
of  pathogenic  bacteria  after  they  have  entered  the  tissues  or  the  general  cir- 
culation. But  should  phagocytosis  prove  unsuccessful  in  destroying  the  mi- 
crobes which  have  reached  the  blood,  there  is  still  another  way  in  which  the 
unassisted  resources  of  the  organism  can  deal  with  them  successfully,  viz.: 
elimination  through  one  or  more  of  the  secretory  or  excretory  organs.  The 
critical  discharges  of  the  ancient  authors — profuse  sweating,  diarrhoea,  and 
copious  secretion  of  urine — in  the  light  of  modern  science  have  received  a 
different  significance,  as  they  are  now  regarded  as  efforts  of  the  vis  medicatrix 
natural  to  throw  off  the  cause  which  produced  the  disease:  the  pathogenic 
microbes  and  their  toxins.  The  kidneys  and  the  mucous  membrane  of  the 
intestinal  canal  are  the  organs  most  concerned  in  the  process  of  elimination. 
That  microbes  in  an  active  state  are  eliminated  by  the  kidneys  is  shown  by 
various  observations,  and  this  is  an  important  point  to  remember  as  prob- 
ably explaining  certain  cases  of  pyelitis  occurring  in  patients  who  have  never 
had  any  instrument  passed,  and  in  whom  the  urethra  and  bladder  are  per- 
fectly normal.  The  salivary  glands,  more  especially  the  parotid,  occasion- 
ally take  part  in  the  elimination  of  pus-microbes,  thus  offering  an  explana- 
tion of  the  not  infrequent  occurrence  of  abscesses  in  this  gland  after  sup- 


182  PEINCIPLES    OF    SUEGERY. 

puration  elsewhere.  The  frequency  with  which  the  kidneys  are  affected  in 
cases  of  tuberculosis  furnishes  an  evidence  that  elimination  of  bacilli  takes 
place  through  these  organs.  Philipowicz  produced  tuberculosis  in  animals 
by  injecting  urine  taken  from  tubercular  subjects  into  the  peritoneal  cavity. 
ISTeumann  found  the  specific  microbes  in  the  urine  in  cases  of  typhus,  sep- 
ticasmia,  and  pygemia.  In  a  case  of  acute  endocarditis  and  osteomyelitis  he 
cultivated  from  the  urine  the  staphylococcus  pyogenes  aureus.  He  asserts 
that  the  microorganisms  which  circulate  in  the  blood  localize  in  the  capil- 
lary vessels  of  the  kidney,  where  they  often  cause  minute  multiple  lesions 
without  implication  of  the  entire  parenchyma  of  the  organ.  Through  the 
altered  tissues  some  of  the  microbes  enter  the  tubuli  urinif  eri,  and  are  washed 
away  with  the  urine.  Philipowicz  found  bacilli  in  the  urine  in  anthrax  and 
glanders.  Schweiger  has  shown  conclusively,  by  his  bacteriological  re- 
searches, that  the  urine  from  scarlatinal  patients  is  contagious;  for  varicella, 
typhus  recurrens,  and  malaria  the  same  holds  true.  Schweiger  regards  all 
kidney-lesions  occurring  in  the  course  of  infective  diseases  of  microbic  origin. 
To  prove  that  microbes  pass  through  the  kidneys,  he  cultivated  a  bacillus 
which  Eeimann  discovered  in  the  pus  of  ozsena.  This  bacillus  is  stained  an 
intense-green  color  in  a  culture  of  gelatin  and  agar  after  tAventy-four  hours. 
A  culture  of  this  bacillus  was  diluted  with  a  physiological  solution  of  salt  and 
injected  directly  into  the  circulation.  The  experiments  Avere  made  on  a  dog, 
cat,  and  rabbit.  A  certain  length  of  time  intervened  between  the  injection 
and  the  appearance  of  bacilli  in  the  urine,  as  though,  somewhere  on  their 
way,  an  obstacle  had  been  met  with.  At  first  only  isolated  bacilli  were  found 
in  the  urine,  but  later  on  they  appeared  in  larger  numbers.  Bacteriological 
examinations  of  milk  have  shown  that  different  kinds  of  pathogenic  bacteria 
are  eliminated  through  the  mammary  gland.  Von  Eiselsberg  demonstrated 
by  cultivation  experiments  the  presence  of  staphylococcus  pyogenes  aureus 
in  the  sweat  of  a  pyemic  patient,  and  after  death  he  found  the  same  microbe 
in  the  blood  of  different  organs.  The  chapter  on  "Bacteria"  would  not  be 
complete  without  at  least  alluding  briefly  to  what  is  known  in  reference  to 

DIEECT  TEAlSrSMISSION  OF  PATHOGENIC  BACTEEIA  FEOM  PAEENTS  TO  FCETUS. 

That  many  of  the  infectious  surgical  diseases  are  hereditary  has  been 
admitted  by  the  best  authorities  for  a  long  time,  and  many  theories  have 
been  advanced  to  explain  their  transmission  from  parents  to  child.  The 
modern  views  on  this  subject  may  be  narrowed  down  to  two  suppositions: 

1.  Transmission  from  parents  to  child  of  a  predisposition  to  certain  diseases. 

2.  Direct  transmission  from  parents  to  foetus  of  the  essential  cause  of  the 
disease.  The  supposed  hereditary  predisposition  is  interpreted  as  meaning 
some  congenital  anatomical  or  physiological  defects  in  the  tissues  which 
render  the  organism  unduh''  susceptible  to  the  action  of  post-natal  microbic 


TEANSMISSION  OP  PATHOGENIC  BACTEKIA  FEOM  PAKENTS  TO  FffiTUS.       183 

infection.  The  existence  of  minute  anatomical  defects  of  blood-vessels, 
lymphatic  vessels  and  glands,  connective-tissue  spaces,  etc.,  has  been  ad- 
vanced in  explanation  of  a  greater  liability  of  infection  with  floating  mi- 
crobes, which  enter  the  circulation  after  birth. 

An  inherited  defective  vital  resistance  on  the  part  of  the  tissues  to  the 
action  of  bacteria  is  also  considered  by  many  in  the  light  of  a  congenital 
influence  in  the  causation  of  disease.  The  above-mentioned  conditions  are 
recognized,  but  no  satisfactory,  demonstrative,  or  experimental  proofs  of 
their  existence  have  as  yet  been  furnished,  and  yet  the  immunity  of  some 
animals  to  certain  diseases  cannot  be  explained  in  any  other  way  than  in 
attributing  to  the  tissues  anatomical  or  physiological  properties  which  pro- 
tect the  organism  against  the  action  of  certain  microorganisms  which,  in 
other  animals  not  so  protected  by  inherited  qualities,  produce  a  serious  or 
fatal  disease.  Clinical  observation  also  teaches  us  that  a  great  difference 
exists  among  different  persons  in  reference  to  the  degree  of  susceptibility  to 
the  same  form  of  infection.  In  many  persons,  for  instance,  inoculation  with 
a  pure  culture  of  tubercle  bacilli  would  be  a  perfectly  harmless  procedure; 
in  some  it  would  be  followed  by  a  localized  tubercular  process  which,  in  the 
course  of  time,  might  heal  spontaneously;  while  in  a  few,  rendered  more 
susceptible  to  this  form  of  infection  by  hereditary  or  acquired  causes,  in- 
oculation with  the  same  number  of  bacilli  would  be  followed  by  a  severe  form 
of  local  tuberculosis,  soon  to  be  followed  by  regional  and  general  dissemina- 
tion and  death.  The  same  can  be  said  of  nearly  all,  if  not  all,  infectious 
diseases.  //  their  existence  has  not  teen  demonstrated,  we  are,  nevertheless, 
forced  to  accept  the  influence  of  certain  as  yet  unhnmvn  conditions  inherent 
in  the  tissues,  and  which  are  often  traceahle  to  a  congenital  cause  or  causes 
w'hich  favor  or  resist  post-natal  microMc  diseases.  During  the  last  few  years 
some  progress  has  been  made  in  showing  that  hereditary  diseases,  in  many 
instances  at  least,  are  due  to  a  more  direct  cause:  transmission  from  parents 
to  foetus  of  the  essential  cause  of  the  disease, — pathogenic  microbes.  Al- 
though our  knowledge  of  the  intrauterine  origin  of  microbie  diseases  is  as 
yet  imperfect,  there  can  be  no  doubt  that  future  study  and  research  will  clear 
up  many  dark  points  and  furnish  satisfactory  demonstrative  explanations 
of  the  direct  and  indirect  hereditary  influences  in  the  causation  of  disease. 
It  is  well  known  that  small-pox,  measles,  and  scarlatina  are  directly  trans- 
missible from  mother  to  foetus.  Numerous  well-authenticated  cases  of  these 
diseases  occurring  in  newborn  children  have  been  recorded.  Lebedeff  reports 
a  case  of  premature  birth  which  occurred  eight  days  after  the  mother  had 
recovered  from  erysipelas.  The  child  died  ten  minutes  after  birth,  and  the 
author  found  Fehleisen's  streptococcus  in  the  lymphatic  vessels,  in  the  dis- 
eased skin,  and  in  the  umbilical  cord,  but  none  in  the  placenta.  The  author 
believes  that  the  streptococci  were  transported  from  the  lymphatic  vessels 


184  PEINCIPLES    OF    SURGEKY. 

of  the  lower  extremities  of  the  mother  through  the  lymphatics  of  the  uterus 
into  the  placental  vessels,  and  from  the  maternal  into  the  fcetal  circulation. 
Ahlfeld  and  Marchand  report  the  case  of  a  woman  who  presented  no  symp- 
toms of  disease  except  a  moderate  pallor  and  tympanitic  distension  of  the 
abdomen.  After  a  normal  labor  she  gave  birth  to  her  second  child;  eight 
hours  after  delivery  the  patient  died  in  collapse,  for  which  no  cause  could 
be  found.  The  autopsy  revealed  anthrax  as  the  cause  of  death.  The  child 
died  four  days  after  birth,  from  the  same  cause.  The  mother,  as  was  later 
ascertained,  contracted  the  disease  in  sorting  horse-hair,  and  the  child  was 
infected  directly  through  the  placental  circulation.  Sangalli  found  the 
bacilli  of  anthrax  in  the  blood  of  a  foetus  from  a  woman  who  had  died  of 
anthrax.  In  opposition  to  Grolzi  and  others,  he  afhrms  that  the  transmission 
of  the  disease  from  mother  to  foetus  could  only  have  taken  place  by  the 
passage  of  the  bacilli  or  spores  from  the  maternal  to  the  fcetal  circulation 
through  the  placental  vessels.  Netter  reports  a  carefully-observed  case  of 
direct  transmission  of  the  diplococcus  of  pneumonia  from  mother  to  foetus. 
The  mother  was  a  Yl-para,  pregnant  eight  months,  when  she  was  attacked 
with  croupous  pneu'monia,  which  terminated  on  the  seventh  day  in  recov- 
ery. On  the  ninth  day  after  the  attack  she  was  delivered  of  a  living  child. 
The  child  died  on  the  fifth  day  after  birth.  The  autopsy  revealed  lobar 
pneumonia  involving  the  right  upper  lobe,  double  fibrinous  pleuritis,  peri- 
carditis, suppurative  meningitis,  and  otitis  media  on  both  sides.  Bacterio- 
logical examination  of  the  different  inflammatory  products,  as  well  as  of 
the  blood  taken  from  the  left  ventricle,  showed  the  presence  of  Frankers 
diplococcus  pneumoniae.  One  of  the  strongest  evidences  of  direct  trans- 
mission of  pathogenic  microbes  from  mother  to  foetus  through  the  placental 
circulation  is  the  often-quoted  observation  made  by  Johne.  An  eight 
months'  foetus  was  taken  from  a  cow  the  subject  of  advanced  tuberculosis. 
No  tuberculous  products  were  found  in  the  placenta  or  the  uterus,  but  in 
the  lower  lobe  of  the  right  lung  of  the  foetus  a  nodule  the  size  of  a  pea  was 
detected,  containing  four  caseous  centres.  The  bronchial  glands  were  tuber- 
cular. The  liver  contained  numerous  miliary  nodules.  All  the  lesions  pre- 
sented, under  the  microscope,  the  characteristic  histological  structure  of 
tubercle.  Jani  has  examined  the  healthy  sexual  organs  of  nine  phthisical 
patients  for  tubercle  bacilli.  No  bacilli  were  found,  in  any  of  these,  in  the 
semen  from  the  vesiculge  seminalis,  but,  on  the  other  hand,  in  5  out  of  8 
cases,  a  few  were  found  in  the  testicle,  and  in  4  out  of  6  in  th'e  prostate 
gland.  He  further  examined  two  women  who  died  of  pulmonary  phthisis, 
the  ovaries  in  both  presenting  negative  results.  In  one  case  of  chronic  pul- 
monary phthisis,  with  extensive  intestinal  tuberculosis,  he  examined  the 
Eallopian  tubes,  and  found  tubercle  bacilli.  He  believes  that  the  tubercular 
^    virus  can  be  transmitted  from  parents  to  offspring  in  one  of  two  ways: 


TRANSMISSION  OF  PATHOGENIC  BACTERIA  FROM  PARENTS  TO  FCETUS.       185 

1.  Through  the  semen  of  the  male.  2.  Through  the  migration  of  bacilli  into 
the  uterus  .from  the  abdominal  cavity.  The  frequency  with  which  the 
Fallopian  tubes  are  the  seat  of  tubercular  lesions  makes  it  more  than  prob- 
able that  the  ovum,  on  its  way  from  the  ovaries  to  the  uterine  cavity,  is  in- 
fected with  bacilli.  It  also  requires  no  stretch  of  the  imagination  to  under- 
stand how  the  spermatozoa  in  the  testicle  or  on  its  way  to  the  vesiculse 
seminalis  can  be  contaminated  with  bacilli,  and  thus  the  disease  directly 
transmitted  from  father  to  foetus. 

That  syphilis  is  a  microbic  disease  can  no  longer  be  doubted,  and  that 
it  is  one  of  the  diseases  which  is  most  frequently  transmitted  from  parents 
to  offspring  is  well  known. 

That  pathogenic  microorganisms  may  exist  in  the  blood  of  apparently 
healthy  mothers  without  doing  any  harm  is  well  illustrated  by  children  who 
have  been  born  suffering  from  suppurative  osteomyelitis,  while  the  mothers, 
through  whose  blood  only  the  microorganisms  could  have  come,  showed  no 
evidences  of  disease.  Eosenbach  reports  such  a  case  in  his  article  on  acute 
osteomyelitis.  Transmission  of  microbic  diseases  through  the  placental  cir- 
culation has  been  made  the  subject  of  experimental  inquiry.  Strauss  and 
Chamberland  experimented  on  guinea-pigs  to  prove  that  intrauterine  trans- 
mission of  anthrax  from  mother  to  offspring  is  possible.  Gravid  animals 
were  inoculated  with  the  virus  of  anthrax,  and  the  foetuses  examined  im- 
mediately after  death.  Blood  taken  from  the  cavities  of  the  heart  and  liver, 
examined  under  the  microscope,  never  showed  bacilli.  Cultivation  experi- 
ments were  made  with  the  foetal  blood  in  veal-bouillon,  and  these  proved 
that  in  some  instances  the  blood  of  all  foetuses  from  the  same  mother  con- 
tained bacilli,  sometimes  from  the  same  litter  all  cultures  remained  sterile, 
while  in  some  the  blood  of  only  one  foetus  would  yield  a  positive  result. 
From  these  experiments  the  authors  came  to  the  conclusion  that  the  tissues 
of  the  placenta  offer  no  insurmountable  obstacle  to  the  passage  of  the  bacil- 
lus of  anthrax  from  the  maternal  into  the  foetal  circulation.  Koubassoff 
came  to  more  positive  results  in  his  experiments.  In  all  of  his  experiments 
the  foetuses  of  the  infected  animals  contracted  the  disease  in  utero.  Fie  also 
found  that  time  played  an  important  role  as  far  as  the  number  of  bacilli  in 
the  foetus  was  concerned,  as,  the  longer  the  period  which  intervened  between 
the  inoculation  and  the  death  of  the  mother,  the  more  numerous  were  the 
bacilli  in  the  foetal  organs,  showing  that  the  migration  of  microbes  from  the 
maternal  to  the  foetal  side  of  the  placenta  is  continuous.  Inoculation  with 
attenuated  virus  proved  that  intraiiterine  transmission  took  place  more 
slowly.  Inoculation  of  gravid  animals  with  a  very  strong  culture  nearly 
always  proved  fatal  to  the  foetuses.  Most  all  authors  agree  that,  when  ex- 
travasations or  other  pathological  processes  occur  in  the  placental  attach- 
ment, the  direct  entrance  of  microbes  from  the  maternal  into  the  foetal  cir- 


186  PEINOIPLES    OF    SURGERY. 

culation  is  not  only  possible,  but  a  probable  occurrence.  Abnormality  of 
the  placental  circulation  must,  therefore,  be  recognized  as  a  condition  which 
•favors  the  occurrence  of  hereditary  microbie  disease.  Both  clinical  observa- 
tion and  experimental  research  leave  no  room  for  doubt  that  in  some  infectious 
diseases,  at  least,  heredity  is  traceable  to  direct  transmission  of  the  specific 
microbes,  either  by  means  of  transportation  by  the  spermatozoa  to  the  ovum 
or  by  their  entrance  through  the  thin  wall  which  separates  the  maternal  from 
the  fecial  circulatimi.  It  is  no  more  difficult  to  explain  the  migration  of  mi- 
crobes through  such  a  thin  septum  than  their  transportation  from  one  tis- 
sue to  another  and  from  organ  to  organ  in  other  parts  of  the  body,  more 
especially  as  the  anatomical  conditions  for  mural  implantation  in  the 
placental  yessels  are  most  favorable  for  such  an  occurrence. 


CHAPTER  VII. 


Necrosis. 


Keceosis,  gangrene,  mortification,  and  sphacelus  are  terms  nsed  syn- 
onymously to  indicate  the  death  of  a  part.  English  and  American  writers 
have  nsnally  restricted  the  meaning  of  the  word  necrosis  to  death  of  bone, 
while  the  remaining  terms  were  used  to  express  the  same  condition  affecting 
the  soft  tissues.  Recently  a  sharp  distinction  has  been  made  between  ne- 
crosis and  gangrene  from  an  etiological  stand-point,  according  to  which 
necrosis  is  said  to  have  taken  place  when  the  circulation  and  nutritive 
changes  in  a  part  have  completely  ceased  to  be  followed  by  gangrene  as  soon 
as  saprophytic  bacteria  invade  it  and  give  rise  to  putrefaction.  Death  of 
bone  will  never  be  described  as  gangrene,  and  the  moist  putrefactive  form 
of  gangrene  of  the  soft  tissues  will,  in  all  probability,  be  never  designated 
by  the  term  (necrosis.  Necrosis  of  bone  takes  place  in  the  same  manner  and 
results  from  the  same  causes  as  gangrene  of  the  soft  parts,  and  on  this  ac- 
count there  does  not  appear  to  be  sufficient  reasons  to  apply  different  terms 
to  identical  processes  occurring  in  different  anatomical  structures;  and  yet 
by  long  usage  they  have  become  so  intimately  associated  with  the  anatom- 
ical character  of  the  part  affected  that  it- is  difficult,  for  the  present  at  least, 
to  drop  either.  In  modern  literature  we  speak  of  necrosis  of  the  soft  tissues 
when  the  dead  structures  do  not  undergo  putrefaction;  that  is,  when  this 
process  takes  place  in  the  internal  organs  not  readily  accessible  to  putre- 
factive bacteria,  or  when  it  involves  external  parts  and  is  unattended  by 
putrefaction.  In  its  extent  necrosis  varies  greatly;  it  may  involve  an  entire 
limb,  an  entire  organ,  or  may  be  limited  to  a  single  cell.  As  a  physiological 
process  it  occurs  everywhere  in  the  tissues,  being  limited,  however,  to  indi- 
vidual cells  incident  to  the  wear  and  tear  of  the  body,  the  pulling  down  and 
building  up  of  the  tissues,  the  cells  that  are  lost  being  replaced  by  the  nor- 
mal process  of  regeneration.  A  simple,  numerically-increased  cell-necrosis, 
without  normal  restitution,  leads  to  atrophy:  necrosis  atrophica.  When  all 
the  cells  of  a  part  undergo  death  simultaneously,  the  circulation  correspond- 
ing to  the  area  of  dead  tissue  is  arrested  completely,  and  with  this  absolute 
ischsemia,  plasma-circulation,  and  all  functions  are,  of  course,  completely 
suspended:   a  serious  pathological  condition,  a  total  necrosis,  has  occurred. 

ETIOLOGY. 

Necrosis  is  a  condition,  not  a  disease.  As  a  symptom,  it  represents  a 
local  condition  which  has  been  brought  about  by  different  causes.  The  most 
frequent  causes  of  necrosis  are  the  following: — 

(187) 


188  PRINCIPLES    OF    SUEGEEY. 

Inflammation. — Inflammation  may  produce  necrosis  in  two  different 
ways:  1.  Exudation  and  transudation  take  place  so  rapidly  that  complete 
stasis  is  produced  by  the  extravascular  pressure.  2.  The  bacterial  cause  of 
the  inflammation  is  present  in  such  large  quantities  that  the  vitality  of  the 
tissue  is  destroyed  directly  from  this  cause.  If  during  an  acute  inflamma- 
tion the  capillary  walls  undergo  such  serious  alteration  that  within  a  few 
hours  or  days  the  connective-tissue  spaces  become  so  densely  packed  with 
the  corpuscular  elements  of  the  blood  that  the  plasma-circulation  is  greatly 
impeded  or  completely  arrested,  the  primary  inflammatory  product  en- 
croaches upon  the  capillary  vessels  to  such  an  extent  as  to  completely  arrest 
the  already  sluggish  circulation.  If  such  a  copious  and  rapidly-forming  in- 
flammatory exudate  give  rise  to  complete  stasis  over  a  considerable  area,  the 
extent  of  the  resulting  necrosis  will  correspond  to  the  district  deprived  of 
the  requisite  blood-su.pply.  The  same  bacteria  which  produce  inflammation 
frequently,  if  present  in  sufficient  quantities,  also  cause  cell-necrosis.  Ogston 
maintains  that  the  staphylococci  invade  the  tissues  in  the  form  of  dense, 
round  masses,  which  advance  like  clouds  of  a  dense  vapor,  and,  coming  in 
contact  with  the  tissues,  induce  necrosis,  the  cells,  nuclei,  and  intercellular 
substance  being  changed  into  a  homogeneous,  wax-like  substance  before 
purulent  liquefaction  occurs.  On  the  other  hand,  the  streptococci  of  sup- 
puration invade  the  intercellular  spaces,  the  nuclei  of  the  cells  remaining 
visible.  Bonome  found  the  staphylococcus  pyogenes  aureus  in  such  meta- 
static and  broncho-pneumonic  foci  which  presented  a  gangrenous  character. 
He  maintains  that  the  staphylococcus  at  first  produces  in  the  lungs  a  ne- 
crosis by  its  multiplication,  and  that  suppurative  inflammation  follows  later 
around  the  necrotic  tissue.  Putrefaction  of  the  dead  tissue  develops  in  con- 
sequence of  the  entrance  of  saprophytic  bacilli  through  the  bronchial  tubes. 
He  verified  these  assertions  by  experiments.  He  obtained  pure  cultures  of 
the  yellow  coccus  from  such  pulmonary  foci  made  hj  parenchymatous  pul- 
monary injections,  and  succeeded  in  producing  artificially  identical  lesions 
in  the  lungs  of  animals.  The  same  result  was  obtained  by  the  intravenous 
introduction  of  small  particles  of  elder-pith  impregnated  with  pure  cultures 
of  the  yellow  staphylococcus.  The  gangrenous  foci  produced  by  emboli  con- 
taminated with  the  yellow  coccus  presented  a  characteristic  appearance. 
The  centre  of  such  foci,  at  an  early  stage,  is  composed  of  necrotic  tissue  and 
remnants  of  dead  leucocytes.  The  dead  tissue  is  surrounded  by  a  granular 
zone,  which  is  again  inclosed  by  a  hremorrhagic  zone,  and  beyond  this  an 
area  of  catarrhal  pneumonia.  The  staphylococci  occupy  the  central  portion 
and  from  here  invade  the  granular  zone,  where  putrefactive  bacteria  are  also 
found.  The  pus-microbes  do  not  reach  the  hemorrhagic  zone,  or  the  tissues 
the  seat  of  catarrhal  pneumonia.  As  Bonome  was  unable  to  produce  gan- 
grene of  the  lung,  either  by  parenchymatous  injections  of  other  bacteria. 


ETIOLOGY.  189 

as  the  pneumococcus  or  microsporam  septicum,  or  by  aseptic  emboli  of  elder- 
pith,  he  naturally  came  to  the  conclusion  that  the  gangrene  resulted  from 
the  specific  effect  of  the  yellow  coccus.  He  compares  gangrene  of  the  lung 
with  furuncle  of  the  skin  from  an  etiological  stand-point.  There  can  be  no 
doubt  that  the  primary  effect  of  pus-microbes,  when  brought  in  contact  with 
living  tissue,  under  certain  circumstances,  is  to  produce  necrosis  before  suffi- 
cient time  has  elapsed  for  parenchymatous  inflammation  to  become  estab- 
lished. This  occurs  in  gangrene  of  the  lung,  furuncles,  carbuncles,  and 
endocarditis  haderica  staphylococcvca.  In  the  ordinary  connective-tissue  ab- 
scess, however,  the  connective-tissue  cells  undergo  the  ordinary  inflamma- 
tory changes  before  they  are  converted  into  pus-corpuscles,  and  if  gangrene 
occur  it  is  owing  as  much  to  mechanicabobstruction  of  the  circulation  caused 
by  a  copious  exudate  as  to  the  local  toxic  effects  of  the  pus-microbes  and 
their  toxins.  This  difference  in  the  action  of  pus-microbes  on  the  tissues 
depends  largely  upon  the  rapidity  with  which  they  multiply  at  the  point  of 
primary  localization.  If  the  microbes  are  rapidly  reproduced,  the  chemical 
substances  which  they  produce  in  the  tissues  are  present  in  such  large  quan- 
tities that  they  destroy  the  cell-protoplasm,  and  cell-necrosis  takes  place  as 
the  result  of  their  primary  action;  if  the  microbes  multiply  with  less  rapid- 
ity, their  effect  on  the  tissues  is  less  severe,  and  parenchymatous  inflamma- 
tion is  produced  instead  of  necrosis.  Bonome  used  large  quantities  of  pus- 
microbes  in  his  injections,  and  the  infected  emboli  caused  circulatory  dis- 
turbances, which  only  could  favor  rapid  reproduction  at  the  point  of  pri- 
mary localization.  Passet  and  Liibbert  repeated  his  experiments,  but  used 
more  diluted  cultures,  and  probably  on  this  account  they  were  never  suc- 
cessful in  producing  gangrene  of  the  lung,  while  they  frequently  observed 
the  development  of  a  pulmonary  abscess.  The  centre  of  a  furuncle,  as  well 
as  a  carbuncle,  is  occupied  by  a  mass  of  dead  connective  tissue,  which  later 
becomes  detached  by  suppurative  inflammation.  The  connective  tissue  in 
these  cases  is  killed  by  the  bacterial  cause  of  the  suppurative  inflammation, 
which,  toward  the  periphery,  appears  to  become  mitigated;  so  that,  behind 
the  suppurating  zone,  a  wall  of  granulation  tissue  is  established  which  limits 
further  extension  of  the  disease. 

Specific  Bacteria.  —  All  bacteria  which  can  produce  an  inflammation 
sufficiently  severe  to  completely  arrest  circulation  can  become  an  indirect 
cause  of  necrosis.  Among  these  can  be  included  the  pus-microbes  and  the 
bacillus  of  anthrax.  The  necrosis  which  occurs  regularly  almost  in  every 
case  of  anthrax  is  probably  due  to  the  intensity  of  the  inflammation  result- 
ing from  the  presence  of  the  anthrax  bacillus,  to  secondary  infection  with 
pus-microbes,  or  to  the  combined  effect  of  both  microbes.  The  absence  of 
necrosis  in  artificially-produced  anthrax,  when  pus-microbes  are  excluded  by 
the  strictest  aseptic  precautions,  does  not  prove  that  the  anthrax  bacilli 


190  PEINCIPLES    OP    SURGEEY. 

possess  no  necrotic  effect  on  the  tissue,  as  in  such  instances  death  follows 
so  soon  that  not  sufficient  time  intervenes  between  the  inoculation  and  the 
death  of  the  animal  for  the  local  inflammation  to  terminate  in  necrosis. 
Necrosis  is,  however,  much  more  likely  to  occur  if  the  anthracic  infection  is 
complicated  by  the  presence  of  pus-microbes.  It  is  well  known  that  certain 
chemical  substances  have  the  power  to  produce  cell-necrosis  independently 
of  their  action  to  excite  inflammation.  Digitoxin,  a  poisonous  principle  of 
digitalis,  is  one  of  these.  The  primary  effect  of  this  substance  on  the  tissues 
is  to  produce  cell-necrosis.  We  should  expect  that  some  of  the  toxins  possess 
similar  properties.  Orthmann  made  some  very  interesting  experiments  in 
this  direction  with  pus-microbes.  He  inoculated  both  cornese  in  rabbits  by 
making  a  puncture  with  a  needle  infected  with  a  pure  culture  of  the  strep- 
tococcus pyogenes.  One  of  the  eyes  was  irrigated  for  ten  minutes  with  a 
warm  physiological  solution  of  salt,  by  using  an  apparatus  constructed  for 
this  special  purpose.  In  the  eye  not  thus  treated  a  suppurative  keratitis  was 
initiated  by  the  leucocytes  from  the  conjunctival  sac  reaching  the  infected 
field,  while  in  the  cornea  treated  by  irrigation  the  streptococci  invaded  the 
vascular  spaces,  and,  multiplying  with  great  rapidity,  produced  by  their  ac- 
cumulation dilatation  of  the  spaces  and  necrosis  of  the  fixed  tissue-cells. 

In  most  of  these  cases  the  central  necrosis  led  to  perforation  of  the 
cornea  and  complete  destruction  of  the  eye.  As  the  corneal  corpuscles  in 
the  necrotic  area  had  lost  their  nuclei  and  the  parenchyma-cells  showed  no 
signs  of  inflammation,  we  cannot  escape  the  conclusion  that  cell-necrosis 
was  induced  by  the  direct  action  of  the  toxins,  elaborated  by  the  masses  of 
streptococci  in  the  vascular  spaces.  The  most  conclusive  proof  of  the  de- 
structive effect  of  toxins  on  the  tissues  has  been  furnished  by  the  great  mas- 
ter and  founder  of  modern  bacteriology,  Eobert  Koch.  In  his  experiments 
on  septicsemia  in  mice  he  found,  besides  bacilli,  a  micrococcus  in  the  neigh- 
borhood of  the  place  of  injection.  Of  the  numerous  kinds  of  bacteria  con- 
tained in  the  putrid  fluid  used  for  injection,  only  the  fine  bacilli  upon  which 
the  induction  of  the  septicaemia  depended  and  the  chain  cocci  found  a  suit- 
able soil  in  the  mouse,  while  all  the  rest  perished.  The  chain  coccus  was 
never  found  in  the  blood,  but  only  in  the  tissues  at  the  seat  of  infection.  He 
found  it  exceedingly  difficult  to  isolate  it  from  the  bacillus.  At  last  he 
succeeded  in  cultivating  it  in  the  field-mouse,  which,  as  experiments  proved, 
is  immune  to  the  bacillus  of  septicaemia.  The  chain  coccus  injected  into  the 
subcutaneous  tissue  of  the-  ear  of  the  field-mouse  invaded  the  tissues  slowly, 
causing  paleness  and  death  of  the  cells  without  extravasation.  The  microbe 
entered  and  plugged  the  capillary  vessels,  but  never  found  its  way  into  the 
general  circulation.  Examination  of  the  specimens  showed  that  progressive 
gangrene  occurred  in  advance  of  the  microbes,  hence  could  have  occurred 
only  by  the  action  of  toxins  diffused  through  the  tissues  ahead  of  the  mi- 


ETIOLOGY. 


191 


erobic  invasion.  Inflammation  of  the  fixed  tissue-cells  occurred  around  the 
zone  of  gangrene,  and  all  leucocytes  which  reached  the  infected  field  per- 
ished. If  the  same  animal  was  inoculated  at  the  root  of  the  tail,  gangrene 
occurred  and  spread  in  a  central  direction,  and  resulted  in  death  on  the  third 
day.  The  microbe  did  not  change  in  its  morphology  or  pathogenic  prop- 
erties after  passing  through  a  series  of  inoculations.  Both  Ogston  and  Ro- 
senbach  are  of  the  opinion  that  the  chain  micrococcus  with  which  Koch 
produced  progressive  gangrene  in  the  field-mouse  is  identical  with  the  strep- 
tococcus pyogenes.    Baumgarten  is  of  the  opinion  that  microbes  can  produce 


A 


Pig.  83.— Experimentally-produced  Growth  of  Streptococci  in  Centre  of  Cornea  of 
Rabbit.  Horizontal  Section.  X  40.  A,  normal  cornea;  B,  central  necrotic  portion,  corre- 
sponding in  outline  to  the  star-shaped  streptococcic  culture.     (Baumgarten.) 


necrosis  not  only  by  the  production  of  a  tissue-poison,  but  also  by  causing 
decomposition  and  by  the  assimilation  of  material  necessary  for  cell-nutri- 
tion. The  explanation  advanced  by  Koch  more  than  twenty  years  ago,  how- 
ever, appears  more  rational:  "Introduced  by  inoculation  (chain  cocci)  into 
living  animal  tissues,  they  multiply,  and  as  a  part  of  their  vegetative  process 
they  excrete  soluble  substances,  which  get  into  the  surrounding  tissues  by 
diffusion,  and  when  greatly  concentrated,  as  in  the  neighborhood  of  the 
micrococci,  this  product  of  the  organisms  has  such  a  deleterious  action  on 
the  cells  that  these  perish  and  finally  disappear  completely.     At  a  greater 


192  PEINCIPLES    OF    SURGERY. 

distance  from  the  micrococci  the  poison  becomes  more  diluted  and  acts  less 
intensel}^^  only  producing  inflammation  and  accumulation  of  lymph-corpus- 
cles. Thus  it  happens  that  the  micrococci  are  always  found  in  the  gan- 
grenous tissue,  and  that  in  extending  they  are  preceded  by  a  wall  of  nuclei 
which  constantly  melts  down  on  the  side  directed  toward  them,  while  on 
the  opposite  side  it  is  as  constantly  renewed  by  lymph  deposited  afresh." 

An  almost  identical  form  of  gangrene,  as  experimentally  produced  in 
the  iield-mouse  by  Koch,  is  occasionally  met  with  in  man.  It  is  known  as 
progressive  gangrene,  and  is  so  called  from  its  most  conspicuous  clinical 
feature :  rapid  extension.  Before  antiseptic  surgery  was  known  it  frequently 
developed  in  cases  of  compound  fracture  and  compound  dislocation  of  large 
joints,  and  often  proved  the  direct  cause  of  loss  of  limb  or  life,  or  both.  Two 
cases  came  under  my  own  observation  where  it  occurred  after  extirpation  of 
carcinoma  of  the  breast,  in  one  without,  and  in  the  other  with,  removal  of 
the  axillary  glands.  In  both  cases  the  first  symptoms  appeared  on  the  third 
day.  The  general  symptoms  were  those  of  intense  sepsis,  while  the  local 
conditions  resembled  first  what  used  to  be  called  phlegmonous  erysipelas. 
An  erysipelatous  blush  appeared  at  the  margins  of  the  wound  and  extended 
rapidly  in  all  directions,  accompanied  by  infiltration  of  the  deep  tissues. 
The  gangrene  attacked  the  tissues  first  involved  and  followed  the  course  of 
the  phlegmonous  inflammation.  In  spite  of  the  most  energetic  local  and 
general  treatment,  both  patients  died  at  the  end  of  the  first  week.  Eosen- 
bach  describes  two  cases  that  came  under  his  care.  In  one  the  disease  started 
from  a  small  wound  of  a  finger,  the  process  finally  extending  to  the  lower 
extremities,  with  death  on  the  sixth  day.  In  the  second  case  the  local  lesion 
appeared  first  as  a  red  induration,  around  which  oedema  developed  rapidly, 
the  skin  covering  the  part  presenting  a  reddish-blue  discoloration  before 
gangrene  set  in.  This  patient  had  an  eruption  of  the  skin  over  the  whole 
surface  of  the  body  which  resembled  the  rash  of  scarlatina.  From  the  lesions 
of  both  of  these  cases  Eosenbach  cultivated  upon  peptone-meat  gelatin  the 
streptococcus  pyogenes.  Ogston  calls  this  affection  erysipelatoid-wound  gan- 
grene, and  always  found  in  the  gangrenous  tissue  the  streptococcus.  Gan- 
grene produced  by  staphylococcus,  the  same  author -calls  sloughing  inflam- 
mation or  inflammatory  mortification.  The  streptococcus  of  erysipelas  never 
produces  gangrene,  and  when  this  complication  occurs  in  this  disease  it  is 
always  a  positive  indication  that  secondary  infection  with  pus-microbes  has 
taken  place. 

Putrefactive  Bacteria. — Necrosis  occurring  from  the  action  of  any  other 
microbes  than  those  of  putrefaction  is  not  attended  by  any  disagreeable  odor 
or  other  evidences  of  putrefaction,  and,  if  limited  in  extent  and  protected 
against  the  invasion  of  saprophytes,  the  dead  tissue,  if  limited  in  quantity, 
may  be  completely  removed  by  absorption.     Putrefactive  bacteria  feed  on 


ETIOLOGY.  193 

dead  tissue,  and  in  the  absence  of  siicli  they  are  comparatively  harmless. 
Putrefaction  only  takes  place  in  moist  gangrene,  and  is  always  caused  by 
the  invasion  of  dead  tissue  with  one  or  more  species  of  saprophytes.  Pro- 
gressive gangrene,  complicated  by  secondary  infection  with  saprophytes,  is 
characterized  by  the  formation  of  gases  which  give  rise  to  emphysema. 
Progressive  gangrene  Avith  emphysema  is  one  of  the  most  fatal  of  all  wound 
complications,  as  the  ptomaines  elaborated  by  the  saprophytic  bacilli  greatly 
increase  the  danger  from  sepsis.  Sulphureted  hydrogen  is  one  of  the  gases 
formed  during  putrefaction  of  necrosed  tissue.  Eosenbach  cultivated  from 
the  infected  tissues,  in  two  cases  of  progressive  gangrene  with  emphysema, 
a  saprophytic  bacillus  with  spores.  Hauser  cultivated  from  putrefying  or- 
ganic substances  one  or  more  kinds  of  the  proteus,  the  proteus  mirahilis 
[Zenkeri)  and  vulgaris. 

Trauma. — The  vitality  of  a  part  is  completely  destroyed  if  a  trauma 
is  sufficient  in  intensity  to  arrest  the  circulation  completely,  and  of  such  a 
character  and  extent  as  to  render  a  return  of  it  impossible.  Such  injuries, 
for  instance,  are  caused  by  the  passage  of  a  car-wheel  over  a  limb,  where  the 
skin  often  remains  intact,  while  all  of  the  deeper  tissues  are  completely 
crushed.  A  blow  against  a  part  of  the  body  where  only  a  thin  layer  of  tissue 
is  interposed  between  the  skin  and  an  underlying  bone  may  crush  the  sub- 
cutaneous tissue  to  such  an  extent  as  to  preclude  the  possibility  of  a  return 
of  an  adequate  circulation,  and  necrosis  follows  as  an  inevitable  result. 
Deep-seated  contusions  from  the  ajjplication  of  external  violence  are  often 
attended  by  circulatory  disturbances,  which  necessarily  result  in  necrosis. 
N"ecrosis  of  ganglion-cells  following  contusion  of  the  brain  affords  a  good 
illustration  of  the  occurrence  of  traumatic  necrosis  at  a  distance  from  where 
the  force  was  applied.  In  such  cases  the  cells  are  separated  from  all  their 
anatomical  connections  by  the  trauma,  and  either  undergo  calcification  or 
are  removed  by  absorption.'  If  such  a  contused  area  become  the  seat  of  a 
subsequent  infection,  suppuration  or  putrefaction  can  occur,  according  to 
the  location  of  the  part  injured,  infection  taking  place  with  pyogenic  mi- 
cribes  or  saprophytes.  In  the  so-called  railway-spine  the  cell-necrosis  fol- 
lowing a  contusion  of  the  spinal  cord  leads  to  remote,  central,  and  peripheral 
disturbances.  A  trauma  may  be  of  such  a  nature  as  to  inflict  an  injury  not 
incompatible  with  the  integrity  of  a  limb,  but  may  create  conditions  which 
subsequently  result  in  complete  obliteration  of  a  main  artery.  If  an  artery 
is  subjected  to  serious  pressure  or  traction,  the  intima  gives  way  and  the 
lumen  of  the  vessel  is  subsequently  obliterated  by  the  formation  of  a  throm- 
bus at  the  seat  of  injury.  In  such  a  case  the  artery  is  at  first  permeable, 
and  the  distal  pulsations  are  unafEected  until  the  lumen  of  the  vessel  is 
narrowed  and  finally  completely  obliterated  by  the  formation  of  a  thrombus. 
The  late  Professor  von  Wahl  has  called  attention  to  an  early  and  important 


194  PRINCIPLES    OF    SUEGERY. 

symptom  in  these  cases^  the  detection  of  which  enables  the  surgeon  to  recog- 
nize the  vessel  injury  before  the  appearance  of  the  positive  peripheral  symp- 
tom,-— viz.,  a  hruit, — which  can  be  heard  by  placing  the  stethoscope  over  the 
seat  of  injury.  The  vessel  injury  in  such  cases  is  of  serious  import,  as  the 
contusion  of  the  soft  tissues  which  is  usually  also  present  retards  or  prevents 
the  formation  of  an  adequate  collateral  circulation,  and  gangrene  occurs  in 
consequence  of  complete  interruption  of  the  arterial  circulation.  A  vein 
may  be  injured  in  a  similar  manner,  and  the  venous  stasis  following  oblitera- 
tion by  a  thrombus  may  become  a  determining  cause  of  gangrene  of  a  limb, 
the  vitality  of  which  has  been  otherwise  impaired  by  the  injury. 

Decubitus. — Prolonged  uninterrupted  pressure  causes  necrosis  by  in- 
terrupting the  circulation.  Tight  bandaging  and  pressure  of  splints  have 
often  been  productive  of  gangrene.  Bed-sores  are  liable  to  form  in  patients 
suffering  from  acute  infectious  diseases,  and  in  persons  suffering  from  fract- 
ure of  the  spine,  or  disease  of  the  spinal  cord;  also,  in  aged  obese  persons 
treated  in  the  recumbent  dorsal  position  for  fracture  of  the  neck  of  the 
femur.  Decubitus  is  most  prone  to  appear  in  consequence  of  pressure  over 
bony  prominences,  and  on  this  account  we  look  for  it  in  persons  who  are 
going  through  a  long-enforced  confinement  in  bed,  first  over  the  sacrum,  the 
trochanteric  regions,  the  spinous  processes  of  the  vertebrae,  and  the  heels: 
parts  most  affected  by  the  dorsal  decubitus.  The  deleterious  effect  of  press- 
ure is  greatly  aggravated  by  filthy  surroundings,  as  under  these  circum- 
stances the  necrosed  tissue  becomes  the  seat  of  infection  with  pus-microbes 
and  saprophytic  bacteria,  which  inaugurate  a  progressive  gangTene  and  sep- 
sis, often  constituting  the  direct  cause  of  death.  It  is  not  unusual,  in  cases 
of  septic  decubitus,  to  find  the  whole  sacrum  exposed,  and  in  one  instance 
that  came  under  the  author's  observation  the  spinal  canal  was  opened  and 
through  the  opening  the  cerebro-spinal  fluid  escaped,  first  clear,  later  puru- 
lent. This  patient  lived  for  several  days  after  the  cerebro-spinal  fluid  had 
commenced  to  escape,  and  before  his  death  he  presented  symptoms  which 
indicated  that  the  meningitis  had  extended  to  the  envelopes  of  the  brain. 

Defective  Arterial  Blood-supply. — The  aseptic  ligature,  combined  with 
the  aseptic  treatment  of  wounds,  has  been  the  means  of  greatly  dimin- 
ishing the  frequency  of  gangrene  after  ligation  of  the  principal  arteries  of  a 
limb  in  their  continuity.  Gangrene  usually  occurred,  not  so  much  from  the 
sudden  interruption  of  the  arterial  blood-supply  as  from  the  septic  inflam- 
mation following  the  operation,  which  interfered  with  the  formation  of  a 
satisfactory  collateral  circulation. 

Ligation  of  Arteries  in  their  Continuity. — Statistics  of  a  number  of 
years  ago  show  that  gangrene  has  followed  ligation  of  the  subclavian  in  the 
outer  third  in  9  per  cent,  of  the  cases  reported;  external  iliac,  15  per  cent.: 
common  femoral,  11  per  cent.     The  results  after  ligation  of  these  vessels 


ETIOLOGY.  ,  195 

have  miicli  improved  since  the  introduction  of  the  aseptic  ligature.  In  a 
healthy  person  with  normal  blood-vessels  there  is  but  little  danger  of  gan- 
grene following  the  ligation  of  the  principal  arteries  of  a  limb  with  an 
aseptic  ligature  under  aseptic  precautions.  Gradual  obliteration  of  an  artery 
by  a  thrombus  is  not  attended  by  equal  danger  of  the  occurrence  of  gangrene 
as  when  the  same  vessel  is  suddenly  and  completely  blocked  by  impaction 
from  the  arrest  of  an  embolus,  because  collateral  circulation  is  on  a  fair  way 
of  becoming  established  before  the  lumen  of  the  vessel  is  completely  closed, 
while  in  the  latter  case  the  demand  on  the  collateral  vessels  is  more  urgent 
and  sudden,  and  consequently  the  failure  on  their  part  to  act  as  substitues 
for  the  obliterated  trunk  is  more  frequent.  Valvular  disease  of  the  heart, 
fatty  degeneration  of  this  organ,  atheroma  of  the  arteries, — in  fact,  all 
pathological  conditions  which  diminish  the  vis  a  tergo, — are  instrumental  in 
the  causation  of  gangrene,  when  from  any  accidental  cause  or  operative 
interference  the  blood-supply  to  a  limb  has  been  diminished,  or  when  the 
tissues  are  the  seat  of  a  progressive  septic  inflammation.  Gradual  diminu- 
tion of  the  arterial  blood-supply  generally  gives  rise  to  dry  gangTene,  as  is 
the  case  in  senile  gangrene,  while  sudden  interruption  of  the  circulation 
through  a  large  artery  from  the  application  of  a  ligature  or  the  impaction 
of  an  embolus  is  usually  followed  by  moist  gangrene. 

Obstructed  Venous  Circulation. — Impeded  venous  circulation  is  fraught 
with  as  much  danger,  as  far  as  the  production  of  gangrene  is  concerned,  as 
obstruction  of  the  arterial  circulation.  Langenbeck  was  impressed  with  this 
fact  so  strongly  that  he  recommended,  if  it  became  necessary  to  ligate  one  of 
the  principal  veins  of  an  extremity  near  the  trunk,  to  ligate  at  the  same  time 
the  accompanying  artery  in  order  to  guard  against  the  evil  results  follow- 
ing ligation  of  a  large  vein.  Aseptic  surgery  has  minimized  the  danger 
of  ligaturing  veins, — for  instance,  the  axillary  or  femoral  vein, — and  no  sur- 
geon at  the  present  time_  would  deem  it  necessar}^,  or  even  justifiable,  to 
ligate  the  corresponding  arteries  simply  for  the  purpose  of  preventing  ex- 
cessive venous  engorgement  and  of  favoring  the  formation  of  an  adequate 
venous  collateral  circulation.  The  same  advantages  which  have  resulted 
from  aseptic  operations  for  the  timely  formation  of  an  arterial  collateral 
circulation  after  ligature  of  an  artery  are  secured  for  the  maintenance  of  an 
inadequate  venous  circulation  after  the  ligation  of  a  vein.  Venous  obstruc- 
tion from  pathological  causes  often  proves  more  disastrous,  as  the  causes 
which  have  brought  about  the  formation  of  a  thrombus  frequently  do  not 
remain  local,  and  the  thrombus  increases  in  length  in  both  directions,  thus 
rendering  the  formation  of  a  collateral  circulation  a  difficult,  if  not  an  im- 
possible, occurrence.  As  venous  obstruction  gives  rise  to  oedema,  gangrene 
— if  it  occur  under  these  conditions — always  represents  the  moist  variety, 
and  is  usually  accompanied  by  putrefaction. 


196  PEINCIPLES    OF    SURGERY. 

Heat. — Heat  produces  pathological  conditions  according  to  the  degree 
of  the  temperature  and  the  length  of  time  a  part  is  exposed  to  its  action.  A 
momentary  exposure  even  to  a  high  temperature  produces  only  a  burn  of 
the  first  degree;  that  is,  simply  an  active  hypergemia  and  redness  of  the  sur- 
face. If  the  part  is  exposed  for  a  somewhat  longer  time  the  hypergemia  is 
followed  by  a  superficial  inflammation  and  blisters  form:  a  condition  which 
is  described  as  a  burn  of  the  second  degree.  In  such  cases  the  necrosis  is 
limited  to  the  epidermis,  which  is  detached  from  the  papillary  layer  by  the 
serous  transudation.  In  burns  of  the  third  degree  the  deeper  tissues  are 
destroyed  by  the  heat,  and  extensive  necrosis  is  the  result.  Cohnheim  de- 
termined that  a  temperature  from  54°  to  58°  C.  was  sufficient  to  produce 
gangrene  in  the  rabbit's  ear.  If  he  immersed  the  ear  for  a  short  time  in 
water  heated  to  this  temperature,  necrosis  always  followed.  A  somewhat 
lower  temperature  continued  for  a  longer  time  produced  the  same  effect. 
Heat  produces  necrosis  by  coagulating  the  cell-protoplasm,  if  its  action  is 
superficial;  if  it  penetrate  more  deeply,  the  blood  in  the  blood-vessels  is 
coagulated,  and  necrosis  of  the  tissues  deprived  of  circulation  in  this  man- 
ner follows  as  an  inevitable  result.  Intestinal  ulceration,  in  case  of  extensive 
burns,  is  also  a  necrotic  process,  caused  by  capillary  obstruction  with  dead 
or  dying  blood-corjDUScles  derived  from  the  burned  district.  It  has  been 
foimd  experimentally  that  a  temperature  over  45°  C.  has  a  destructive  effect 
on  the  blood-corpuscles.  AVelti  ascertained  that  if  the  ear  of  a  rabbit  is 
kept  immersed  in  water,  gradually  heated  to  70°  C,  bleeding  from  the  nose 
and  hsemoglobinuria  followed:  sj^mptoms  which  he  attributed  to  partial  or 
qomplete  obstruction  of  capillary  vessels  with  the  third  corpuscle  of  the 
blood. 

Cold. — The  action  of  cold  in  producing  necrosis  is  closely  allied  to  that 
of  heat.  Frost-bites  are  classified  the  same  as  burns.  Cold,  like  heat,  causes 
gangrene  by  producing  cell-necrosis  and  vascular  obstruction. 

Cohnheim  produced  gangrene  of  the  rabbit's  ear  by  exposing  it  for  a  • 
short  time  to  a  temperature  of  16°  C.  The  length  of  time  a  part  is  exposed, 
either  to  heat  or  cold,  exerts  an  important  influence  in  determining  the 
extent  and  depth  of  the  subsequent  gangrene.  Gangrene  resulting  from  a 
burn  or  exposure  to  cold  remains  dry  and  aseptic  as  long  as  the  entrance 
from  without  of  pus-microbes  and  saprophytes  is  prevented,  but  with  mi- 
crobic  invasion  suppuration  and  putrefaction  are  established. 

Pancreatic  Ferment. — U]2cler  certain  conditions  the  pancreas  undergoes 
acute  fat-necrosis  from  the  action  of  its  own  secretion.  Katz  and  Winkler 
tied  and  divided  the  pancreatic  duct,  being  careful  not  to  injure  the  vessels. 
This  experiment  was  made  on  fifty  dogs,  and  they  found  fat-necrosis  in  all 
of  them.  Hgemorrhage  occurred  almost  always  arormd  the  necrotic  areas, 
and  the  necrosis  was  most  marked  in  the  neighborhood  of  the  liaratures. 


ETIOLOGY.  197 

The  necrosis  was  apparently  due  to  the  action  of  the  fat-splitting  ferment 
of  the  pancreas. 

Caustics. — Chemical  substances  which  by  their  local  action  on  the  tis- 
sues produce  extensive  cell-necrosis  are  called  caustics.  Of  these,  the  strong 
acids  and  mineral  salts  destroy  cells  by  causing  coagulation.  The  necrosed 
tissue,  or  eschar,  resulting  from  their  action  is  firm,  and  the  contour  of  the 
cells  is  well  jDreserved.  The  alkaline  caustics,  on  the  other  hand,  dissolve 
the  tissue-elements,  and  the  slough  resulting  from  their  application  is  soft. 
A  peculiar  form  of  necrosis  of  the  maxillary  bones  occurs  in  persons  ex- 
posed to  the  fumes  of  phosphorus.  The  most  recent  explanation  of  the  oc- 
currence of  necrosis  of  the  jaws  in  persons  employed  in  match-factories  is 
to  the  effect  that  the  phosphorus  fumes  in  the  mouth  are  transformed  into 
phosphoric  acid,  and  that  necrosis  of  the  bone  is  produced  by  the  direct 
action  of  the  acid  on  the  bone  and  myeloid  cells,  while  the  periosteum  re- 
mains intact  and  produces  new  bone. 

Ergot. — -The  prolonged  administration  of  ergot  in  large  doses  is  at- 
tended by  the  risk  of  causing  gangrene.  The  gangrene  from  ergotism  is 
always  of  the  dry  variety.  It  is  generally  believed  that  it  is  caused  by  the 
drug  keeping  up  an  angiospasm,  which  shuts  off  the  full  blood-supply  to 
the  peripheral  portion  of  the  extremities:  the  most  frequent  seat  of  the 
gangrene.  Zweifel,  of  Erlangen,  believes  that  the  toxic  effect  of  ergot  results 
in  a  vasomotor  paresis,  and  that  the  gangrene  is  due  to  defective  innerva- 
tion. 

Raynaud's  Disease. — Symmetrical  gangrene,  or  Eaynaud's  disease,  is  a 
form  of  ischsemia  due  to  contraction  of  the  arterioles.  The  arterial  spasm 
may  extend  to  arteries  the  size  of  the  radial.  EayUaud  recommends  the  use 
of  the  constant  descending  current  to  the  spine. 

Internal  Necrosis.  —  In  simple  cell-necrosis  the  tissue-elements  may 
have  undergone  no  changes  in  form,  but  the  cell-protoplasm  has  lost  its 
vital  properties  and  function  has  been  completely  arrested.  Such  cells  pre- 
sent a  cloudy  appearance,  and  if  the  necrosis  has  resulted  from  a  gradual  or 
sudden  ischsemia  the  part  affected  presents  a  pale  appearance.  In  the 
periphery  of  such  a  necrotic  area  the  vessels  become  dilated  and  an  hyper- 
semic  zone  forms,  in  which  the  collateral  circulation  is  to  be  established.  If 
an  artery  in  any  of  the  internal  organs  is  suddenly  obliterated  by  the  im- 
paction of  an  embolus,  the  tissues  supplied  by  the  closed  vessels  are  deprived 
for  a  time,  and  perhaps  permanent^,  of  their  blood-supply,  and  in  conse- 
quence of  this  they  become  pale,  while  around  the  wedge-shaped  infarct 
the  vessels  concerned  in  the  formation  of  collateral  circulation  are  distended 
to  their  utmost,  and  often  yield  to  the  increased  intravascular  pressure  when 
extravasation  of  blood  occurs.  If  the  collateral  circulation  is  not  speedily 
established,  necrosis  of  the  tissues  supplied  by  the  obliterated  vessel  is  the 


198  PRINCIPLES    OF    SUEGERY. 

result.  In  nij^cotic  cell-necrosis  haryolysis — that  is,  dissolution  of  the  cells 
— usually  occurs.  If  the  cell-membrane  niptnre  and  the  contents  of  the 
cell  'escape,  we  speak  of  a  harijorliexis.  Absolute  ischsemia  of  certain  parts 
or  cell  territories  continued  for  onl}'-  one  to  two  hours  is  sure  to  result  in 
necrosis.  If  any  portion  of  the  brain,  intestines,  or  kidney  is  deprived  of 
blood-supply  for  this  period  of  time,  nutrition  is  completely  suspended,  and 
cell-necrosis  follows  as  an  inevitable  consequence.-  Litten  ligated  the  renal 
artery  in  animals,  and  found,  at  the  end  of  an  hour  and  a  half  to  two  hours, 
the  renal  epitlielia  in  a  state  of  necrosis.  Limited  necrosis  of  the  parenchyma 
of  the  brain  may  give  rise  to  focal  S5rmptoms  by  which  the  lesion  cannot 
only  be  recognized,  but  often  accurately  located.  Infarcts  of  the  kidney 
can  frequently  be  diagnosticated  by  a  careful  chemical  and  microscopical 
examination  of  the  urine.  A  similar  condition  in  the  lungs  gives  rise  to  cir- 
cumscribed catarrhal  pneumonia,  which  can  be  recognized  by  a  careful  phys- 
ical examination  of  the  chest.  Ulcer  of  the  stomach,  the  result  of  a  circum- 
scribed necrosis,  is  attended  by  a  complexus  of  symptoms  pointing  directly 
to  the  seat  and  nature  of  the  lesion.  Necrosis  in  internal  organs  is  not  often 
followed  by  putrefaction,  as  saprophytes  seldom  reach  the  dead  tissue.  Ne- 
crosis of  the  lungs  is  sometimes  followed  by  gangrene,  by  the  entrance  into 
the  necrosed  tissue  of  putrefactive  bacteria  from  the  respiratory  passage. 
Gangrene  of  External  Parts. — As  it  is  often  impossible  to  recognize 
during  life  a  limited  cell-necrosis  in  the  internal  organs  by  the  symptoms 
presented,  this  subject  has  been  briefly  disposed  of,  but  the  symptomatology 
of  external  gangrene  will  receive  a  more  thorough  consideration.  It  might 
appear  that  the  recognition  of  the  existence  of  gangrene  of  any  of  the  ex- 
ternal parts  would  require  no  special  care  or  erudition.  But  this  is  not  so. 
It  is  true  that,  when  gangrene  is  fully  developed,  when  all  the  characteristic 
symptorhs  are  present,  a  correct  diagnosis  can  be  made  on  first  sight.  But 
cases  occur  where  it  is  exceedingly  difficult  to  determine  whether  the  part 
affected  is  dead  or  only  in  a  state  of  inflammation.  In  illustration  of  this 
the  author  will  only  allude  to  the  difficulties  which  surround  the  surgeon  in 
many  cases  of  herniotomy,  when  he  has  to  determine  whether  it  is  justifiable 
to  return  a  portion  of  intestine  that  has  been  strangulated  for  some  time  if 
he  simply  rely  on  the  appearance  of  the  intestine.  The  intestine  presents  a 
dusky,  almost  black,  appearance,  and  the  casual  observer  might  come  to 
the  conclusion  that  it  is  gangrenous  and  treat  it  as  such,  when,  in  fact,  a 
more  careful  observation  will  soon  reveal  the  fact  that  the  circulation  is  not 
completely  arrested,  and  that  it  is  safe  to  return  it. 

SYMPTOMS. 

(a)   Pain. — Sudden,  severe,  often  excruciating  pain  in  a  limb  is  the 
first  indication  which  announces  the  occurrence  of  embolism  in  one  of  the 


SYMPTOMS.  199 

large  arteries.  In  the  lower  extremity  the  embolus  is  often  arrested  at  the 
bifurcation  of  the  popliteal  artery,  but  the  pain  extends  along  the  whole 
limb,  from  the  toes  to  the  groin.  The  sudden  anaemia  is  the  cause  of  the 
pain.  In  senile  gangrene  the  gradual  ischsemia  caused  by  the  atheromatous 
degeneration  of  the  arteries  gives  rise  to  pain  and  a  sensation  of  numbness, 
which  precede  the  gangrene  for  weeks  or  months.  Acute  inflammation  re- 
sulting in  gangrene  is  attended  by  intense  pain  from  the  very  beginning; 
the  pain  abates,  as  a  rule,  with  the  occurrence  of  gangrene.  Pain  may  be 
absent  at  the  seat  of  necrosis,  and  referred  to  some  other  part  or  locality. 
In  strangulated  hernia  the  patient  often  suffers  little  or  no  pain  at  all  in 
the  swelling,  but  complains  of  a  periodical  pain  in  the  region  of  tlie  um- 
bilicus. The  absence  of  pain  and  tenderness  over  the  region  of  a  hernia 
speaks  rather  for  than  against  the  presence  of  gangTene.  Osteomyelitis  is 
attended  by  severe  pain,  which  is  diminished  or  subsides  with  the  escape 
of  the  products  of  inflammation  from  the  bone  into  the  surrounding  tissues. 
In  cases  of  intestinal  obstruction  the  cessation  of  pain,  with  continuance  of 
the  symptoms  of  obstruction,  is  an  indication  that  gangrene  has  occurred. 

(b)  Tenderness. — The  pain  elicited  by  pressure  is  a  more  important 
symptom  in  the  diagnosis  of  necrosis  than  spontaneous  pain.  As  long  as  the 
part  suspected  to  be  necrotic  is  sensitive  to  the  touch  it  is  a  sign  that  necrosis 
has  not  taken  place.  To  test  the  sensation  of  a  part  it  is  advisable  to  resort 
to  puncture  with  an  aseptic  needle.  Absence  of  pain  and  all  sensation  on 
puncturing  the  tissues  with  a  needle  is  often  the  best  argument  to  convince 
the  patient  and  friends  that  necrosis  has  occurred. 

(c)  Temperature. — The  difference  in  the  temperature  of  a  part  threat- 
ened with  gangrene  has  given  rise  to  the  expressions  liot  and  cold  gangrene. 
If  gangrene  follow  an  acute  inflammation  the  local  temperature  remains 
high  until  other  evidences  of  gangrene  make  their  appearance,  when  the 
complete  arrest  of  circulation  and  tissue-metamorphosis  result  in  a  sudden 
fall  of  the  local  temperature.  In  gangrene  following  atheroma,  thrombosis, 
embolism,  and  ligation  of  arteries  the  local  temperature  is  reduced  before 
gangrene  occurs. 

(d)  Pulse. — After  ligation '  of  the  principal  artery  of  a  limb  the  sur- 
geon examines  anxiously,  from  day  to  day,  for  the  appearance  of  pulsation 
in  the  distal  portion  of  the  artery:  an  occurrence  upon  which  depends  the 
fate  of  the  limb.  The  reappearance  of  the  pulsation  in  the  distal  part  of 
the  artery  is  a  certain  indication  that  collateral  circulation  has  become  estab- 
lished, and  that  gangrene  will  not  occur.  With  the  appearance  of  distal 
pulsations  the  local  temperature  increases,  and  the  diminished  tissue-meta- 
morphosis is  restored  to  its  normal  state.  In  embolism  or  thrombosis  of  a 
large  artery  the  same  disturbances  in  the  peripheral  circulation  of  the  limb 
are  observed  as  after  ligation.    By  searching  for  pulsation  in  different  parts 


^00  PEINCIPLES    OF    SURGERY. 

of  the  limb  the  surgeon  can  often  locate  the  thrombus  or  embolus.  If,  for 
instance,  the  embolus  or  thrombus  is  located  in  the  terminal  portion  of  the 
popliteal  artery,  pulsations  of  the  femoral  artery  can  be  felt  from  Poupart's 
ligament  down  to  the  seat  of  obstruction,  while  no  pulsations  below  this 
point  can  be  felt  imtil  collateral  circulation  is  established.  Obliteration  of 
an  artery  from  pathological  causes  is  prone  to  prevent  the  formation  of  an 
adequate  collateral  circulation  by  the  growth,  in  both  directions,  of  the 
thrombus  or  embolus.  The  pulse  furnishes  the  most  important  means  to 
follow  from  day  to  day  the  growth  of  the  intravascular  blood-clot.  In  senile 
gangrene  a  thrombus  frequently  forms  in  one  of  the  smallest  arteries  and 
grows  in  a  proximal  direction,  extending  from  the  digital  branches  to  the 
dorsalis  pedis,  to  the  anterior  tibial,  or  from  the  plantar  arteries  to  the  poste- 
rior tibial,  the  popliteal,  and  finally  the  femoral.  In  such  eases  the  arteries 
can  be  felt  as  firm  cords,  but  pulsations  are  limited  to  the  previous  portion 
of  the  vessels.  An  embolus  often  becomes  the  centre  of  an  enormous  throm- 
bus, which  seriously  impairs  the  chances  of  preservation  of  the  limb  by  the 
establishment  of  an  early  and  adequate  collateral  circulation.  When  an  em- 
bolus obstructs  the  popliteal  artery,  pulsations  can  be  felt  above  this  point, 
but  they  disappear  with  the  extension  of  the  secondary  thrombus  in  a  proxi- 
mal direction. 

(e)  Swelling. — In  moist  gangrene  the  necrosed  tissue  imbibes  moisture 
to  a  considerable  extent,  and  the  slough  is  larger  than  the  tissue  it  repre- 
sents. The  swelling  is  increased  twice  as  much  when  gas  forms  in  the  tis- 
sues. In  dry  gangrene  the  parts  shrink,  become  firmer,  and  instead  of  swell- 
ing there  is  diminution  in  their  size  as  compared  with  their  volume  in  a  nor- 
mal state:   a  condition  called  mummificatvon. 

(f)  Emphysema. — The  presence  of  emphysema  in  gangrenous  tissue  is 
a  certain  indication  of  the  presence  of  gasogenic  bacteria.  The  character 
of  putrefaction  depends  on  the  kind  of  saprophytes  which  are  present  in  the 
dead  tissues.  The  different  kinds  of  proteus  possess  gas-producing  proper- 
ties. The  proteus,  according  to  Hauser,  appears  in  different  forms,  accord- 
ing to  the  chemical  reaction  of  the  soil  upon  which  it  grows.  On  acid 
gelatin  the  culture  consists  of  cocci  and  short  bacilli;  on  alkaline  gelatin 
it  grows  in  the  form  of  threads,  vibrios,  spirilli,  etc.  All  these  different 
forms  of  proteus  growing  in  dead  tissue  exposed  to  the  atmospheric  air  pro- 
duce sulphureted  hydrogen.  Hauser  cultivated  the  proteus  from  ulcerating 
carcinomas  and  bed-sores.  Chiari  reports  an  interesting  observation  con- 
cerning the  production  of  a  septic  emphysema  and  gangrene  caused  by  the 
bacillus  coli  communis.  The  patient  was  suffering  from  diabetes  and 
atheroma.  The  great  toe  was  amputated  for  gangrene.  Gangrene  of  the 
foot  followed,  which  extended  above  the  ankle.  Gussenbauer  amputated 
above  the  knee-joint.     Gangrene  of  the  stump,  with  extensive  emphysema. 


SYMPTOMS.  201 

supervened,  and  the  patient  died  a  few  days  after  the  operation.  The  bacillus 
coli  communis  was  found  in  the  afEected  tissues  and  the  blood,  and  was 
cultivated  in  agar-gelatin  and  grape-sugar.  The  gasogenic  properties  of  this 
microbe  were  well  shown  in  the  cultures.  All  attempts  to  produce  septic 
emphysema  in  animals  with  pvire  cultures  failed,  as  the  animals  died  of  acute 
sepsis.  In  the  cases  of  progressiv.e  gangrene  with  emphysema  examined 
bacteriologically  by  Eosenbach,  he  found  the  bacillus  saprogenes  foetidu.s. 
Emphysema  is  sometimes  so  marked  that  on  percussion  a  tympanitic  reso- 
nance is  elicited.  When  less  in  degree  its  presence  can  be  readily  recognized 
by  pressure,  which  causes  a  crackling,  crepitating  sound.  Hitzmann  and 
Lindenthal  describe  a  new  anaerobic  bacillus  which  they  isolated  in  four 
of  five  cases  of  gangreri'e-  foud7-oyante.  It  is  a  large  bacillus  with  rounded 
ends,  staining  by  Gram's  method,  non-sporogenic,  non-capsulated,  and  im- 
motile.  It  produces  gas,  both  from  carbohydrates  and  proteids,  and  is 
pathogenic  for  guinea-pigs,  producing  the  same  lesions  as  in  man,  while 
rabbits  are  refractory  and  mice  frequently  so.  It  is  widely  distributed  in 
nature,  and  occurs  in  the  intestinal  canal.  One  of  the  gasogenic  microbes 
which  is  now  attracting  a  good  deal  of  attention  and  which  is  often  found 
in  emphysematous  inflammatory  products  is  the  bacillus  aerogenes  capsu- 
latus,  (Welch).  Museatello  and  Gangati  claim  that  this  bacillus  is  without 
pathogenic  action  in  healthy  tissues,  but  that  it  produces  gaseous  gangrene 
when  it  comes  in  contact  with  tissues  of  reduced  vitality.  It  causes  death 
from  toxaemia,  and  post-mortem  it  spreads  throughout  the  body. 

(g)  Color. — If  gangrene  take  place  in  consequence  of  interrupted  arte- 
rial circulation,  the  part  at  first  presents  a  preternaturally  pale  appearance 
until  the  first  visible  evidences  of  the  actual  occurrence  of  gangrene  are  an- 
nounced by  a  livid  or  lead  color,  at  a  point  where  the  circulation  has  first 
been  completely  arrested.  The  lividity,  when  it  is  due  to  complete,  irrep- 
arable capillary  stasis,  is  not  affected  by  pressure.  Blisters  containing  a 
sanious  fluid  form  at  points  where  the  deeper  tissues  have  already  undergone 
necrosis.  As  soon  as  the  circulation  has  been  completely  arrested,  tissue- 
metamorphosis  is  at  once  suspended,  and  the  further  changes  are  entirely 
of  a  chemical  nature.  The  colored  corpuscles  of  the  blood  undergo  rapid 
disintegration;  the  coloring  material  is  diffused  through  the  dead  tissue  and 
into  the  interior  of  the  bullae.  The  black  color  of  gangrenous  tissue  is  pro- 
duced by  sulphuret  of  iron:  a  combination  of  sulphureted  hydrogen  and 
haemoglobin. 

(h)  Condition  of  Tissues. — The  condition  of  the  dead  tissues  will  de- 
pend on  the  cause  of  the  necrosis.  In  dry  gangrene  they  become  firmer  by 
evaporation  of  the  fluids.  In  moist  gangrene  they  imbibe  fluids  and  undergo 
maceration,  becoming  soft  and  friable.  In  moist  gangrene  a  fetid,  sanious 
fluid  escapes  from  the  dead  tissue.    Adipose  tissue  in  a  condition  of  gangrene 


203  PEINCIPLES    OF    SUEGEEY. 

undergoes  speedy  disintegration,  and  free  globules  of  fat  are  mixed  with 
the  sanious  discharge.  Maceration  of  tissue  is  considered  by  Eavoth  as  the 
most  important  condition  in  determining  the  presence  of  gangrene  in  cases 
of  strangulated  hernia.  lie  maintains  that  if  the  tissues  of  the  intestinal 
wall  can  be  readily  separated  and  teased  asunder  with  a  dissecting  forceps 
there  can  be  no  doubt  that  gangrene  has  occurred.  This  maceration,  how- 
ever, takes  place  only  some  time'  after  the  circulation  has  ceased,  and  i^ 
entirely  absent  in  necrosis  of  bone,  cartilage,  and  tissues  well  supplied  with 
elastic  elements,  as  the  arteries.  In  determining  the  presence  of  gangrene 
in  strangulated  hernia,  where  any  doubt  as  to  its  presence  exists  in  the  mind 
of  the  operator,  it  is  much  better  to  liberate  the  strangulated  loop,  draw  it 
forward,  and  irrigate  it  every  few  minutes  with  a  hot  solution  of  salt,  which 
will  stimulate  the  sluggish  circulation,  and  will  soon  furnish  reliable  proof 
of  the  actual  condition  of  the  vessels  and  the  tissues.  Mechanical  stimula- 
tion of  the  intestinal  wall  is  also  a  valuable  diagnostic  measure,  as,  if  gan- 
grene has  occurred,  no  amount  of  irritation  will  excite  peristaltic  action, 
while  with  the  restoration  of  the  impeded  circulation  the  muscular  fibres 
will  respond  to  irritation. 

(i)  Odor. — Necrosed-  tissue  does  not  emit  any  unpleasant  odor  unless 
it  has  become  invaded  with  putrefactive  bacteria.  The  almost  unbearable 
stench  which  attends  extensive  moist  gangrene  is  always  the  result  of  putre- 
factive changes.  Dry  gangrene  is  odorless.  In  acute  inflammatory  affections 
of  the  lung,  where  a  communication  has  been  established  between  the  in- 
flammatory focus  and  the  bronchial  tubes,  the  presence  or  absence  of'  f oetor 
is  of  great  diagnostic  value,  as  its  presence  speaks  in  favor  of  gangrene  and 
its  absence  indicates  an  abscess-. 

(j)  Mummification.---By-  this  term'  we  mean  a  drying  up  of  a  gan- 
gTenous  soft  part  from  the  loss  of  fluids  which  it  contains  by  evaporation. 
It  is  a  state  of  preservation  of  dead  tissue  while  still  attached  to  the  living 
body.  It  can  only  occur  if  the  dead  tissue  is  exposed  to  the  atmospheric 
air,  and  on  this  account  it  is  always  absent  in  necrosis  of  internal  organs. 
Mummification  can  only  take  place  where  putrefaction  is  absent,  and,  there- 
fore, is  most  frequently  met  with  where  gangrene  is  first  limited,  and  in- 
creases gradually  by  an  aggravation  of  the  causes  which  produce  gradual 
diminution  of  the  arterial  blood-supply,  as  in  cases  of  senile  gangrene. 

(k)  Line  of  Demarcation.^ — The  line  of  demarcation  is  the  line  where 
the  farther  extension  of  gangrene  has  been  arrested  by  an  adequate  collateral 
circulation  and  a  wall  of  living  granulations.  Back  of  this  line  of  demarca- 
tion, on  the  side  of  the  living  tissues,  there  is  to  be  found  an  hypersemic 
zone,  which  precedes  and  attends  the  regenerative  process,  and  by  which  the 
farther  extension  of  the  gangrene  is  prevented.  In  septic  gangrene  the  line 
of  demarcation  marks  the  limits  of  the  area  of  infection,  while  in  aseptic 


SYMPTOMS.  •  SOS 

gangrene  it  indicates  the  point  where  the  vascular  conditions  answer  the 
physiological  requirements  of  the  part. 

(1)  Elimination  of  Gangrenous  Part. — Spontaneous  elimination  of  a 
gangrenous  part  is  of  frequent  occurrence.  The  necrotic  tissue  may  be  dis- 
posed of  in  a  spontaneous  cure  in  three  different  ways:  1.  Absorption  of 
dead  tissue.  2.  Separation  of  necrosed  part  by  granulation.  3.  Separation 
of  the  sphacelus  or  sequestrum  by  suppuration.  A  limited  quantity  of 
necrosed  aseptic  tissue  can  be  completely  removed  by  absorption  in  the  same 
manner  as  absorbable  aseptic  substances  are  removed  when  implanted  in  the 
tissues.  This  is  the  most  desirable  termination  of  gangrene,  and  takes  place 
frequently  in  cell-necrosis  of  the  internal  organs.  Such  a  disposal  of  aseptic 
necrosed  tissue  is  also  possible  on  the  surface  of  the  skin  when  the  area  does 
not  exceed  a  square  inch,  and  an  aseptic  condition  is  secured  throughout. 
The  capacity  of  the  tissues  to  remove  aseptic  necrosed  tissue  is  limited,  and 
when  the  quantity  of  tissue  surpasses  this  capacity  the  dead  part  is  consid- 
erably diminished  in  size,  and  the  balance  is  detached  by  the  granulations 
which  form  at  the  line  of  demarcation,  and  is  finally  eliminated  spontane- 
ously or  by  operation.  Eepair  after  this  manner  of  elimination  is  rapid  and 
satisfactory.  If  infection  with  pus-microbes  has  taken  place  in  the  begin- 
ning of  the  lesion  which  has  caused  the  necrosis,  or,  later,  at  the  line  of 
demarcation,  separation  of  the  slough  takes  place  by  means  of  a  suppurative 
inflammation.  In  such  cases  the  dead  part  is  not  diminished  in  size,  and  the 
healing,  after  its  elimination,  takes  place  more  slowly,  and  the  result,  as  a 
rule,  is  less  satisfactory.  Separation  takes  place  very  slowly  in  necrosis  of 
bones,  intermuscular  connective  tissue,  and  tendons,  requiring  often  Aveeks 
and  months  before  the  dead  tissue  can  be  removed. 

(m)  Liquefaction  of  Necrosed  Tissue. — In  internal  necrosis  where  no 
putrefaction  or  suppuration  takes  place,  and  the  amount  of  necrosed  tissue 
exceeds  the  absorptive  capacity  of  the  surrounding  tissues,  liquefaction  takes 
place,  and  months  and  years  later  the  seat  of  necrosis  is  occupied  by  what 
appears,  and  has  often  been  falsely  described,  as  a  cyst.  This  method  of  dis- 
posing of  the  dead  tissue  is  observed  most  frequently  in  organs  scantily  sup- 
plied with  connective  tissue,  as  the  brain  and  spinal  cord  and  in  adipose 
tissue. 

(n)  Encapsulation. — A  limited  area  of  aseptic  necrosed  tissue,  not 
amenable  to  absorption,  is  often  rendered  harmless  by  encapsulation.  The 
surrounding  living  tissue  throws  out  a  wall  of  granulation-tissue  which  is 
converted  into  connective  tissue,  forming  a  capsule  around  the  dead  tissue. 
This  method  of  disposal  of  dead  tissues  frequently  occurs  in  the  internal 
organs.  A  sequestrum  occasionally  becomes  encapsulated  after  the  interior 
of  an  involucrum  has  been  rendered  spontaneously,  or  by  treatment,  aseptic. 

(o)    General  Symptoms. — These  will  have  reference  to  the  loss  of  func- 


20-i  PRINCIPLES    OF    SUEGERY. 

tion  caused  by  cell-necrosis  in  internal  organs  and  sepsis  in  external  necrosis. 
Function  will  be  affected  according  to  the  location  and  extent  of  cell-ne- 
crosis. If  cell-necrosis  is  of  mycotic  origin  and  general,  it  frequently  be- 
comes a  direct  cause  of  death.  If  it  is  limited  to  a  single  organ,  the  symptoms 
will  point  to  it  as  the  seat  of  the  disease.  Limited  areas  of  cell-necrosis,  in 
most  of  the  organs,  may  give  rise  to  ill-defined  or  no  symptoms  whatever, 
and  are  then  completely  beyond  the  grasp  of  a  correct  diagnosis.  The  most 
important  general  symptoms  of  gangrene  arise  from  the  introduction  into 
the  general  circulation  from  the  gangrenous  part  of  soluble  toxic  substances. 
As  this  subject  will  be  treated  of  more  extensively  in  the  chapter  on  "Sep- 
ticemia," it  will  suffice  here  to  make  the  broad,  but  correct,  statement  that 
septicaemia  complicates  gangrene  only  when  the  dead  tissues  are  infected 
with  pus-microbes  or  putrefactive  bacteria.  Dry  gangrene  is,  therefore,  not 
attended  by  any  danger  of  septic  intoxication;  while  patients  suffering  from 
moist  gangrene  with  putrefaction  die,  as  a  rule,  not  from  the  loss  of  tissue 
from  gangrene,  but  from  sepsis  incident  to  the  gangrene.  Sepsis  in  gan- 
grene is  usually  of  that  variety  which  arises  from  the  introduction  into  the 
circulation  of  preformed  toxins,  the  symptoms  subsiding  with  the  removal 
of  the  cause,  with  the  exception  of  those  cases  of  progressive  sepsis  caused  by 
infection  with  pus-microbes. 


CHAPTEE  VIII. 

Necrosis  (continued). 

PATHOLOGICAL   AND    CLINICAL    VAEIETIES    OF    NECEOSIS. 

The  pathological  and  clinical  classification  of  necrosis  is  based  upon 
its  causes,  location,  extent,  and  the  age  of  the  patient.  The  causes  of 
necrosis  have  already  been  considered,  and  it  has  been  shown  that  it  results 
either  from  arrest  of  the  circulation  from  purely  mechanical  causes  or  from 
the  action  upon  the  tissues  of  toxic,  chemical,  or  thermal  influences  which 
destroy  the  protoplasm  of  the  cells  directly.  The  location  of  the  necrosis 
is  important  to  remember,  as  when  it  occurs  in  organs  inaccessible  to  sapro- 
phytic microorganisms  putrefaction  never  takes  place;  on  the  other  hand, 
necrosis  in  parts  accessible  to  atmospheric  air  is  prone  to  be  followed  by 
putrefaction,  with  all  the  dangers  which  attach  themselves  to  this  condition. 
The  extent  of  the  gangrene  has  an  important  bearing  on  the  prognosis,  as, 
when  the  causes  are  such  as  to  determine  a  circumscribed  form  of  the  dis- 
ease, life  is  not  in  danger,  while  the  progressive  form,  with  few  exceptions, 
ends  in  death,  in  spite  even  of  the  most  heroic  treatment.  The  age  of  the 
patient  often  determines  the  form  "of  gangrene,  as,  for  instance,  senile  gan- 
grene is  a  disease  of  the  aged,  while  noma,  almost  without  exception,  attacks 
only  children.  The  simplest  and  an  exceedingly  common  form  of  necrosis 
is  what  has  been  described  by  Weigert  as 

Coagulation-necrosis. — This  is  essentially  a  cell-necrosis.  It  is  called 
coagulation-necrosis  because  the  tissues  present  the  appearance  of  coagulated 
albumen,  and  also  on  account  of  the  process  resembling  coagulation  of  the 
blood.  Coagulation-necrosis  is  probably  identical  with,  or,  at  any  rate, 
nearly  allied  to,  the  h3raline  degeneration  of  Eecklinghausen  and  fibrinous 
degeneration  of  E.  Wagner. 

The  chemical  process  which  results  in  coagulation-necrosis  is  as  yet 
imperfectly  understood.  Weigert,  who  was  the  first  to  describe  this  form 
of  necrosis,  maintains  that  the  cell-protoplasm  and,  perhaps,  all  albumen- 
containing  substances  are  converted  by  it  into  a  substance  resembling  fibrin. 
Macroscopically,  tissues  which  have  undergone  this  form  of  necrosis  present 
a  yellowish  or  whitish  appearance,  and  are  of  variable  consistence.  Under 
the  microscope  the  cells  either  appear  unchanged  in  form  or  their  place  is 
occupied  by  thread-like  fragments  and  granular  material.  Weigert  lays  down 
as  the  earliest  change  witnessed  in  a  cell  undergoing  coagulation-necrosis 
disappearance  of  the  nucleus,  which  is  the  case  twelve  to  twentj^-four  hours 
after  the  process  commenced.     Fibrin  is  a  product  of  coagulation-necrosis 

(205) 


206  PEINCIPLES    OF    SUEGEEY. 

of  the  blood.  According  to  Alexander  Schmidt,  during  the  coagulation  of 
blood  the  colorless  corpuscles  disappear;  the  product  of  their  destruction  is 
fibrin-ferment  and  fibrinoplastic  material,  which,  with  the  fibrinogen  of  the 
plasma,  form  fibrin.  Isolated  cells  destroyed  by  coagulation-necrosis  ex- 
foliate, and  are  transformed  into  a  homogeneous  granular  substance,  which, 
according  to  circumstances,  is  removed  by  absorption  or  becomes  encapsu- 
lated. Cell-necrosis  &n  masse  is  often  followed  by  calcification,  and  on  sur- 
faces by  ulceration.  The  transformation  of  a  tubercular  product  into  a 
cheesy  mass  is  the  result  of  coagulation-necrosis.  As  essential  conditions 
for  coagulation-necrosis  to  occur  Weigert  enumerates:  1.  Death  of  tissue- 
cells.  2.  Presence  of  plasma-fluids.  3.  Tissues  must  contain  coagulable 
substances.  An  entire  organ  may  be  destroyed  by  coagulation-necrosis. 
Pale  infarcts  after  embolism  are  products  of  this  change.  The  so-called 
fibrin  wedges,  which  were  formerly  regarded  as  decolorized  blood-clots, 
consist  of  such  tissues.  At  first  the  cells  are '  normal  in  outline  and 
appearance;  later,  the  nuclei  disappear  and  the  cells  break  up  into  granu- 
lar masses.  In  the  internal  organs  coagulation-necrosis  is  most  fre- 
quently met  with  in  the  kidneys,  spleen,  typhoid  deposits,  tubercular 
lesions,  the  vicinity  of  mycotic  foci,  and  in  atheroma  of  the  blood-vessels. 
In  the  parenchyma  of  organs  it  attacks  the  epithelial  cells,  while  the 
connective  tissue  remains  intact.  On  mucous  surfaces  it  is  represented  by 
the  diphtheritic  and  croupous  exudations.'  While  the  chemical  processes  ivhich 
take  place  in  coagulation-necrosis  cannot  as  yet  he  explained  satisfactorily,  there 
can  he  no  douht  that  this  form  of  necrosis  is  nearly  alivays,  if  not  alivays,  of 
mycotic  origin,  and  it  must  he  regarded  practically  in  the  light  of  a  hacterial 
necrosis.  Ivlebs  describes  the  same  condition  as  haryolysis,  Jcaryorhexis,  and 
vacuolar  degeneration.  He  claims  that  early  disappearance  of  the  nucleus  is 
not  an  essential,  but  an  accidental,  condition.  In  a  case  of  pseudodiphtheria 
Klebs  found  the  bacilli  between  cells  devoid  of  nuclei,  and  only  in  the 
centre  of  the  necrotic  patch  did  he  find  bacilli  within  the  cells;  from  this 
he  concluded  that  karyolysis  is  due  to  the  action  of  chemical  products  of 
the  bacilli.  In  the  second  group  of  mycotic  necroses  the  process  differs  as 
in  typhus.  Here  the  necrotic  centre,  which  contains  no  cells,  is  surrounded 
by  a  zone,  in  which  both  cells  and  nuclei  are  also  absent,  but  which  contains 
a  large  number  of  chromatin  bodies,  lying  free  in  the  tissues.  As  these 
bodies  are  found  in  a  location  where  the  cells  and  nuclei  have  been  destroyed, 
it  can  hardly  be  doubted  that  they  represent  remnants  of  these  structures. 
According  to  Wolmkom  and  Graessle,  these  bodies  are  liberated  by  rupture 
of  the  nuclear  envelope.  This  method  of  cell-destruction  is  called  Jcaryo- 
rhexis. A  third  form  of  cell-necrosis  is  vacuolar  degeneration,  in  which  the 
change  is  initiated  in  the  protoplasm  itself.  This  must  not  be  mistaken  for 
cell-oedema.     In  vacuolar  degeneration  the  protoplasm  ruptures,  and  the 


PATHOLOGICAL   AND    CLINICAL   VARIETIES    OF   NECEOSIS.  307 

nuclei  of  epithelial  cells^,  which,  line  a  hollow  visciiS;  are  liberated,  as  Lang- 
hans  observed  in  this  form  of  cell-necrosis  in  the  kidney.  The  cell  ruptures 
on  account  of  increased  intracellular  pressure,  and  the  process  well  deserves 
the  name  plasma-rJiexis.  This  form  of  cell-destruction  was  formerly  consid- 
ered a  post-mortem  change.  For  the  sake  of  simplicity  it  is  advisable  to  sub- 
stitute for  the  different  forms  of  cell-necrosis  described  by  Klebs  the  gen- 
eral term,  coagulation-necrosis,  devised  by  Weigert. 

Necrobiosis. — -This  is  a  term  applied  by  Virchow  to  the  spontaneous 
wearing  out  of  living  parts.  Death  of  isolated  cells  is  a  physiological  process 
as  long  as  they  are  replaced  by  new  cells  of  the  same  tissue  type.  Necro- 
biosis occurring  on  a  more  extensive  scale  is  a  pathological  condition,  and 
is  etiologically  identical  with  coagulation-necrosis.  The  term  can  be  used  to 
signify  circumscribed  cell-necrosis  without  reference  to  its  etiology  or  mi- 
nute morbid  anatomy. 

Progressive  Gangrene. — This  form  of  gangrene  is  always  of  bacterial 
origin.  The  microbe  most  frequently  found  in  the  tissues  is  the  streptococ- 
cus pyogenes.  It  occurs  most  frequently  after  wounds  which  open  up  a  large 
surface  of  loose  connective  tissue,  as  in  compound  fractures,  compound  dis- 
locations, excision  of  the  breast,  with  removal  of  axillary  glands  and  extirpa- 
tion of  large,  fatty  tumors.  The  streptococcus  pyogenes  invades  the  con- 
nective-tissue spaces  rapidly,  somewhat  after  the  manner  of  diffusion  of  the 
streptococcus  through  the  lymphatic  vessels.  Much  of  the  connective-tissue 
necrosis  results  from  the  direct  action  of  the  pus-microbes  and  their  toxins 
on  the  cells.  The  necrosis  of  the  skin  is  no  indication  of  the  extent  of  the 
disease  in  the  deeper  tissues.  The  infection  is  initiated  by  a  chill,  and  the 
fever  which  follows  resembles  severe  sepsis  from  other  causes.  If  infection 
occur  during  the  operation,  or  at  the  time  of  accident,  the  first  symptoms 
may  be  looked  for  within  forty-eight  to  seventy-two  hours.  If  suppuration 
has  occurred  it  is  diminished  with  the  appearance  of  septic  infection,  and 
the  discharge  becomes  thinner  and  sanious.  Lymphangitis  frequently  ac- 
companies the  deep-seated  phlegmonous  inflammation.  Gangrene  appears 
in  the  tissues  first  affected,  and  spreads  rapidly  along  the  connective  tissue. 
Not  only  the  gangrene  is  progressive,  but  also  the  attending  septicasmia. 
The  larger  the  area  of  necrosis,  the  more  extensive  the  field  for  the  growth 
of  pus-microbes  and  putrefactive  bacteria.  Progressive  gangrene  is  an  ex- 
ceedingly dangerous  form  of  infection,  and  unless  treated  by  heroic  meas- 
ures at  an  early  stage  is  sure  to  lead  to  a  speedy  fatal  termination. 

Progressive  Gangrene,  with  Emphysema. — Etiologically  this  form  of 
gangrene  is  identical  with  the  preceding  plus  secondary  infection  ivitJi  ga- 
sogenic  hacteria.  The  necrosed  tissue  answers  the  purpose  of  a  nutrient  me- 
dium for  saprophytic  microorganisms,  which  not  only  generate  gas  which  is 
diffused  through  the  dead  tissues,  but  the  soluble  toxic  substances  which  they 


308  PKINCIPLES    OF    SURGEEY. 

elaborate  in  the  necrotic  area  are  absorbed  into  the  circulation:  an  occur- 
rence which  gives  rise  to  toxsemia.  Emphysema  almost  always  extends  far 
beyond  the  limits  of  the  visible  gangrene,  but  its  presence  is  a  sure  indica- 
tion of  the  extent  of  the  infection  in  the  deep-seated  tissues.  Progressive 
gangrene,  with  emphysema,  is  the  most  fatal  form  of  gangrene,  and  only  in 
exceptional  cases  will  the  surgeon  succeed  in  warding  ofE  a  certain  fatal  ter- 
mination by  early  operative  interference.  In  both  kinds  of  progressive  gan- 
grene the  part  is  swollen,  cedematous,  the  skin  presenting  first  a  livid,  bluish 
color,  which  afterward  shades  into  a  greenish  or  reddish-black  hue.  Bullge, 
containing  a  reddish  serum,  form  at  points  where  the  gangrene  is  spread- 
ing. Besides  sulphureted  hydrogen,  butyric  and  valerianic  acids,  ammonia, 
sulphur,  etc.,  are  some  of  the  many  chemical  products  of  putrefaction.  The 
rapidity  with  which  progressive  gangrene,  with  and  without  emphysema, 
spreads  has  led  the  French  authors  to  apply  to  it  the  term  gcongrene  foudroy- 
ante. 

Moist  Gangrene. — Progressive  gangrene  is  necessarily  a  moist  gangrene, 
as  bacteria  cannot  germinate  without  moisture.  All  forms  of  m3^cotic  gan- 
grene are  forms  of  moist  gangrene.  All  necroses  in  the  interior  of  the  body 
belong  to  this  variety.  The  moisture  of  the  dead  tissue  is  due  to  imbibition 
of  the  oedema-fluid,  and  consequently  moist  gangrene  is  apt  to  follow  vas- 
cular conditions  in  which  there  is  some  impediment  to  the  return  of  venous 
blood,  as  in  cases  of  obstruction  in  a  large  artery,  and  more  especially  when 
a  large  vein  has  become  obliterated  by  a  thrombus.  Moist  gangrene  is  at- 
tended by  all  the  dangers  incident  to  putrefaction.  In  this  form  of  gan- 
grene the  line  of  demarcation  is  the  seat  of  suppurative  inflammation. 

Dry  Gangrene. — In  dry  gangrene  the  dead  tissue  undergoes  mummifica- 
tion, and  on  this  account  the  soil  is  unfitted  for  the  germination  of  putre- 
factive bacteria.  Dry  gangrene  is  usually  the  result  of  a  trauma,  the  action 
of  a  chemical  substance,  or  it  follows  a  gradually-diminishing  blood-supply. 
In  senile  gangrene  it  follows  in  consequence  of  a  gradual  diminution  of 
blood-supply,  owing  to  atheromatous  degeneration  of  the  arteries,  while  the 
return  of  venous  blood  remains  unimpaired.  Dry  gangrene  is  often  an  asep- 
tic gangrene.  If  no  infection  take  place  with  pus-microbes,  the  line  of  de- 
marcation is  formed  by  granulation-tissue,  and  the  gangrenous  part,  if  small, 
is  absorbed,  or  if  this  is  impossible  on  account  of  its  size  it  is  separated  by 
the  granulations.  If  suppuration  take  place  this  occurs  at  the  junction  of 
the  dead  with  the  living  tissues.  Dry  gangrene  is  usually  not  attended  by 
any  general  symptoms,  and  all  attempts  to  remove  the  dead  tissue  should  be 
postponed  until  the  line  of  demarcation  has  formed. 

Senile  Gangrene. — This  is  the  gangrene  of  the  aged,  or,  rather,  it  is  the 
gangrene  which  is  caused  by  atheromatous  degeneration  of  the  arteries. 
Senile  marasmus,  in  the  form  of  atheromatous  deo'eneration  of  the  arteries. 


PATHOLOGICAL   AND    CLINICAL   VAEIETIES    OF   NECEOSIS. 


209 


may  occur  in  persons  less  than  40  years  of  age,  and  is  often  absent  in  octo- 
genarians. Senile  gangrene  always  occurs  in  parts  where  the  circulation  is 
feeblest;  consequently  it  usually  commences  in  one  of  the  toes.  If  the  ne- 
crosed tissue  remain  aseptic,  the  rapidity  of  the  extension  of  the  gangrene 
depends  on  the  condition  of  the  blood-vessels.     It  may  remain  limited  to 


Pig.  84. — Dry  Gangrene  of  Foot.     Line  of  Demarcation  well  Defined.     {After  Lehert.') 


one  toe,  or  it  may  extend  from  toe  to  toe,  and  then  creep  along  the  dorsum 
or  plantar  surface  of  the  foot,  or  on  both  sides  simultaneously,  and  extend 
quite  rapidly  to  the  leg  as  far  as  the  knee.  Usually  the  disease  extends  along 
the  course  of  one  of  the  principal  arteries,  and  extends  later  to  other  parts 
of  the  foot  in  consequence  of  greater  embarrassment  of  the  arterial  and 


210  PEIXCIPLES    OF    SURGEEY. 

venous  circulation.  If  infection  in  the  vicinity  of  the  necrosed  tissue  with 
pus-microbes  take  place,  a  suppurative  inflammation  may  follow  senile  gan- 
grene, which  will  give  rise  to  a  progressive  and  rapidly-fatal  form  of  the  dis- 
ease. In  the  dry  form  of  senile  gangrene  the  tissues  mummif}^,  are  firm, 
and  perfectly  black  in  color.  In  the  moist  variety  the  parts  present  the  same 
.appearances  as  in  progressive  gangrene.  If  a  line  of  demarcation  form,  the 
separation  of  the  dead  from  the  living  tissues  requires  an  unusuall}^  long 
time,  as  the  circulation  is  enfeebled  to  such  an  extent  that  tissue-prolifera- 
tion takes  place  very  slowly. 

Diabetic  Gangrene. — It  is  a  well-known  clinical  fact  that  persons  suf- 
fering from  diabetes  are  very  prone  to  be  attacked  by  gangrene.  The  reasons 
for  this  are  as  yet  unknown.  Gangrene  occurring  from  trivial  causes  in  per- 
sons presenting  the  appearances  of  usual  health,  and  in  whom  no  evidences 
of  atheromatous  degeneration  of  the  arteries  can  be  detected,  should  awaken 
the  suspicion  of  the  existence  of  diabetes,  and  no  time  should  be  lost  in 
making  a  careful  examination  of  the  urine.  A  strictly  antidiabetic  diet  has 
often  resulted  in  arresting  further  extension  of  the  gangrene.  Konig  has 
found  that  after  amputation  for  gangrene  in  diabetics  the  quantity  of  sugar 
in  the  urine  is  diminished. 

Decubitus. — Gangrcena  per  d&cubitum  literally  means  gangrene  from 
pressure.  It  occurs  in  consequence  of  pressure  from  splints,  bandages,  and 
the  prolonged  recumbent  position  in  bed,  especially  in  persons  suffering  from 
fracture  of  the  spine,  or  acute  infectious  diseases  attended  by  great  impair- 
ment of  the  circulation.  Pressure  without  infection  is  productive  of  dry 
aseptic  gangrene,  but  usually  gangrene  from  this  source  is  complicated  by 
infection  with  pyogenic  or  putrefactive  bacteria,  or  both.  If  gangrene  from 
pressure  is  inevitable,  it  is  apparent  that  its  occurrence  should  be  met  by 
timely  precautions  for  the  purpose  of  preventing  accidental  infection.  Gan- 
grene from  splint  pressure  can  be  prevented  by  interposing  between  the 
splint  and  bony  prominences  a  thick  cushion  of  salicylated  cottoii.  Bed- 
sores should  be  prevented  by  changing  the  position  of  patient  frequently  and 
protecting  the  parts  most  exposed  to  the  ill  effects  of  pressure  with  fenes- 
trated rubber  cushions,  by  enforcing  absolute  cleanliness,  and  by  keeping  the 
skin  in  a  healthy  condition  by  applications  of  spirituous  lotions.  Both  in 
gangrcena  per  decvMhwi  and  senile  gangrene  the  necrosis  is  caused  by  im- 
pairment or  complete  suspension  of  the  capillary  circulation. 

Noma. — Noma,  cancer  aquaticus,  is  characterized  by  rapid,  gangrenous 
destruction  of  the  cheek,  which  usually  commences  some  distance  from  the 
lips.  This  disease  is  exceedingly  rare  in  this  country,  but  quite  prevalent  in 
the  large  cities  of  Europe.  It  attacks  exclusively  children,  occurring  most 
frequently  between  the  ages  of  3  and  8  years.  Healthy  children  seldom  suffer 
from  this  disease;    it  either  appears  in  badly-nourished,  cachectic  subjects 


PATHOLOGICAL    AND    CLINICAL    VAEIETIES    OF    NECROSIS.  311 

or  it  occurs  as  a  complication  of  some  of  the  eruptive  fevers  or  typhus.  In 
reference  to  the  etiology  of  noma,  little  is  known.  The  almost  constant  oc- 
currence of  the  disease  in  a  distinct  part  of  the  cheek  and  its  limitation  to 
one  side  of  the  face  Avould  indicate  that  it  might  be  the  result  of  some  nerv- 
ous disturbance.  It  is,  however,  more  probable  that  it  is  a  form  of  mycotic 
necrosis.  A  few  observations  on  the  bacterial  origin  of  noma  have  been 
made.  Lingard  found  in  the  tissues  a  long  bacillus,  which  he  believed  was 
the  cause  of  the  disease.  In  gangrenous  stomatitis  in  the  calf,  which  affects 
this  animal  at  particular  seasons  of  the  year,  he  found  bacilli  which  are  very 
similar  in  appearance  to  those  present  in  noma  in  man.  On  cultivation  they 
present  characters  which  render  them  easily  distinguishable  from  other  bac- 
teria, and  on  inoculation  of  these  microorganisms  into  the  calf  a  gangrenous 
stomatitis  is  again  produced. 

Eanke's  investigations  on  noma  led  to  the  following  conclusions:  Dif- 
ferent forms  of  gangrene  resulting  from  noma  can  unquestionably  occur 
spontaneously  in  children  who  have  a  tendency  to  disease  of  this  character; 
that  is,  without  infection  from  contact.  The  frequent  occurrence  of  noma 
in  public  institutions,  and  the  apparent  preference  of  the  disease  for  local- 
ization upon  the  mucous  membrane  of  the  different  openings  of  the  body, 
suggest  that  the  origin  of  it  may  be  referred  to  the  invasion  from  without 
of  microorganisms.  In  the  zone  of  tissue  contiguous  to  that  Avhich  has  un- 
dergone necrosis  may  be  found  cocci  which  in  number  appear  like  a  pure 
culture.  At  the  periphery  of  the  necrotic  zone  which  has  been  invaded  by 
cocci  the  connective  tissue  is  found  in  a  state  of  active  proliferation.  The 
entire  condition  is  suggestive  of  the  tissue-necrosis  in  field-mice,  which  is 
caused  by  a  chain  coccus,  described  by  Koch.  Up  to  the  present  time  the' 
specific  nature  of  the  cocci  which  Eanke  found  in  noma  tissues  has  not  been 
shown.  Schimmelbusch  has  examined  one  case  for  bacteria,  and  found  ba- 
cilli, often  in  pairs  and  sometimes  in  long  filaments,  growing  along  the 
boundary-line  of  the  living  tissues.  The  bacillus  grew  upon  gelatin  without 
liquefying  it,  and  pure  cultures  injected  into  rabbits  caused  abscesses.  Un- 
doubtedly, further  bacteriological  research  will  prove  that  noma  is  a  my- 
cotic necrosis,  and  that  the  dead  tissue,  like  in  other  forms  of  necrosis,  is  sub- 
sequently invaded  with  putrefactive  bacilli.  The  disease  commences  as  a 
circumscribed  livid  spot  upon  the  surface  of  the  mucous  membrane  of  the 
mouth,  and  a  corresponding  portion  of  the  cheek  in  its  entirety  is  indurated. 
Soon  the  color  of  the  affected  mucous  membrane  becomes  darker,  and  the 
skin,  which  at  first  presented  a  dusky  appearance,  is  turned  nearly  black, 
and  the  epidermis  is  elevated  in  a  blister,  which  afterward  is  turned  into  a 
black  eschar.  With  the  separation  of  the  gangrenous  part  an  opening  in  the 
cheek  is  left  without  any  sign  of  a  line  of  demarcation.  The  gangrene 
spreads  in  all  directions,  and,  if  not  arrested  spontaneously  or  by  the  use  of 


213  PEINCIPLES    OF    SUEGERY. 

energetic  measures,  often  destroys  the  entire  cheek.  The  disease  is  not  lim- 
ited to  the  soft  tissues,  but  attacks  the  maxillary  bones,  often  causing  ex- 
tensive necrosis  and  loss  of  teeth.  The  gangrene  seldom  extends  beyond  the 
median  line  in  the  lips,  and  the  tongue  usually  remains  free.  In  the  major- 
ity of  cases  the  disease  is  fatal.  Death  is  preceded  by  symptoms  of  intense 
sepsis,  with  secondary  septic  inflammation  of  some  of  the  internal  organs, 
especially  the  intestines  and  lungs.  In  some  cases  a  gangrenous  affection  of 
the  genital  organs  occurs,  which  in  every  respect  resembles  the  affection  of 
the  cheek.  In  case  recovery  takes  place,  the  defect  caused  by  the  necrosis  has 
to  be  restored  by  a  plastic  operation. 

Hospital  Gangrene. — Gangrcena  nosocomialis,  ulcer ative-wound  diph- 
theriiis,  only  occurs  as  an  infection  of  wounds,  and,  as  the  name  hospital 
gangrene  indicates,  is  seldom  met  with  outside  of  large  unsanitary  hospitals. 
Before  wounds  were  treated  antiseptically,  it  occurred  as  a  frequent  compli- 
cation after  operations  or  open  injuries  in  most  of  the  European  hospitals. 
It  Avas  prevalent  among  the  wounded  during  the  Civil  War.  Thanks  to  the 
labors  of  Lister  and  his  followers,  it  has  now  disappeared  almost  completely 
among  civilized  nations.  The  simple  fact  that  this  dreadful  disease  has  been 
almost  completely  expunged  from  the  oldest  and  most  infected  hospitals  by 
the  aseptic  treatment  of  wounds  furnishes  conclusive  proof  of  its  mycotic 
origin.  Unfortunately,  practical  bacteriology  was  born  too  late  to  take  ad- 
vantage of  the  numerous  opportunities  to  study  the  etiology  of  this  form  of 
wound  infection.  A  feature  of  this  disease  of  unusual  bacteriological  in- 
terest is  the  fact  that  it  attacks  not  only  recent  wounds,  but  also  wounds 
covered  by  healthy  granulations.  A  healthy  granulating  surface  is  consid- 
ered as  a  good,  if  not  an  absolute,  protection  against  the  ordinary  pathogenic 
bacteria  which  infest  wounds,  but  the  microbe  of  hospital  gangrene  mani- 
fests no  such  discretion.  Whether  hospital  gangrene  is  due  to  a  specific 
pathogenic  microbe  or  to  exceptional  pathogenic  power  acquired  by  some 
one  of  the  common  bacteria  which  infest  suppurating  wounds  is  not  known. 
The  latter  view  is  entertained  by  Sternberg.  H.  Vincent  describes  a  bacillus 
which  he  claims  is  the  specitic  cause  of  this  disease.  He  discovered  it  in  the 
membranous  deposit  on  the  ulcerating  surface.  The  organism  is  not 
found  in  the  blood  nor  could  it  be  cultivated  on  any  of  the  usual  nutrient 
media.  Inoculations  in  the  lower  animals  failed  to  reproduce  the  disease; 
hence  he  is  inclined  to  believe  that  its  pathogenic  action  is  confined 
to  man.  The  first  evidence  of  the  appearance  of  hospital  gangrene  is  the 
formation  of  a  yellowish,  pultaceous  mass  upon  the  surface  of  a  recent  wound 
or  upon  a  granulating  surface.  This  mass  can  be  readily  wiped  away,  with 
the  exception  of  the  lowest  layers,  which  are  firmly  attached  to  the  surface. 
The  skin  in  the  immediate  vicinity  of  this  deposit  becomes  red  and  inflamed, 
and  is  soon  displaced  by  the  same  material.    The  original  wound  assumes  a 


PATHOLOGICAL    AND    CLINICAL    VAEIETIES    OF    NECROSIS.  213 

yellowisli-gray  appearance,  and  is  rapidly  enlarged  by  the  extension  of  the 
destructive  process.  Within  three  days  to  a  week  the  wound  is  enlarged  to 
double  its  original  size.  In  this,  the  pulpous,  form  of  the  disease  extension 
toward  the  depth  of  the  wound  is  slow,  as  fascia  and  muscles  offer  consid- 
erable resistance  to  its  progress  in  this  direction.  In  the  ulce^-ative  form  of 
hospital  gangrene  the  wound  or  granulation  surface  becomes  the  seat  of  an 
ichorous  discharge,  and  the  tissues  undergo  rapid  destruction  by  molecular 
disintegration.  The  ulcerative  form  of  hospital  gangrene  makes  more  rapid 
progress  than  the  pulpous.  Although  these  two  forms  occur  as  distinct 
affections  throughout,  combinations  of  the  two  have  been  observed.  Hos- 
pital gangrene,  in  preference,  attacks  small  wou.nds,  as  pun<;tures,  the  bites 
of  leeches,  abrasions,  blistered  surfaces,  etc.  Many  authors  have  been  in- 
clined to  believe  that  diphtheritic  inflammation  of  a  wound  and  hospital 
gangrene  are  identical,  but,  so  far,  no  positive  proof  of  such  identity  has  been 
furnished.  The  clinical  course  of  both  of  these  processes  is  nearly  the  same, 
but  etiologically  and  pathologically  the  differences  are  apparent.  Heine 
claimed  that  he  observed  hospital  gangrene  where  the  wounds  were  infected 
with  virus  from  patients  suffering  from  genuine  diphtheria,  and  again  he 
saw  genuine  diphtheritic  lesions  of  mucous  membranes  in  patients  who  were 
exposed  to  the  contagium  of  hospital  gangrene.  The  general  symptoms  in 
the  beginning  of  an  attack  of  hospital  gangrene  are  not  severe.  The  patient 
complains  of  a  loss  of  appetite  and  a  general  feeling  of  malaise.  In  old  per- 
sons, children,  and  debilitated  subjects,  it  may  prove  fatal  without  the  oc- 
currence of  special  complications.  One  of  the  great  dangers  which  attend 
hospital  gangrene,  especially  the  ulcerative  form,  is  secondary  haemorrhage. 
During  the  pulpy  degeneration  or  molecular  disintegration  of  the  tissues 
vessels  are  implicated,  and  a  sudden  hsemorrhage  from  a  large  vessel  fre- 
quently leads  to  a  rapidly-fatal  termination.  The  large  vessels  show  an 
unusual  resistance  to  the  destructive  effect  of  hospital  gangrene^  but  not  in- 
frequently they  give  way,  especially  if  the  disease  attack  a  stump  after  am- 
putation. Septic  intoxication  is  never  so  well  marked  in  hospital  gangrene 
as  in  diphtheritic  affections  of  mucous  membranes.  Billroth  believes  that 
hospital  gangrene  is  caused  by  a  specific  microorganism  which  is  only  repro- 
duced under  certain  atmospheric  conditions;  hence  the  appearance  of  the 
disease  formerly  in  an  epidemic  form.  Clinical  observations  leave  no  doubt 
that  the  disease  is  carried  from  one  patient  to  another  by  means  of  sponges, 
instruments,  hands,  etc. 

Perforating  Ulcer  of  Stomach  and  Duodenum. — These  ulcers  follow  cir- 
cumscribed necrosis  of  the  wall  of  the  stomach  or  duodenum,  caused  by  a 
diminished  arterial  blood-supply  of  a  limited  vascular  district.  That  these 
ulcers  are  of  vascular  origin  is  shown  by  their  shape  and  direct  relation  to 
an  artery.     The  defect  is  in  the  form  of  a  cone,  the  base  being  directed 


214  PEINCIPLES    OF    SURGERY. 

toward  the  lumen  of  the  viscus,  and  the  apex  corresponds  with  a  small  artery 
which  must  have  been  partially  or  completely  obstructed  before  the  necrosis 
occurred.  These  ulcers  are  sometimes  multiple,  and  in  the  stomach  they 
are  found  in  preference  along  the  lesser  curvature.  After  interruption  of 
the  arterial  circulation  the  wedge-shaped,  ischsemic,  necrosed  portion  is  re- 
moved by  the  action  of  the  gastric  juice,  and  the  ulcer  is  made.  As  per- 
forating ulcer  of  the  stomach  or  duodenum  never  occurs  in  cases  of  ulcera- 
tive endocarditis,  but  selects  in  preference  young  females,  the  causes  of  vas- 
cular obstruction  must  be  of  a  local  nature.  The  sphacelus  shows  molecular 
decay,  but  no  trace  of  inflammation.  Perforating  ulcers  of  the  stomach  and 
intestines  are  of  interest  to  the  surgeon,  because  in  case  of  perforation  their 
treatment  has  been  brought  within  the  legitimate  sphere  of  successful  ab- 
dominal surgery.  The  more  frequent  occurrence  of  perforation  is  prevented 
by  circumscribed  plastic  peritonitis,  which  seals  the  defect  or  establishes  an 
adhesion  between  the  affected  portion  of  the  organ  and  some  adjacent  sur- 
face. 

Perforating  Ulcer  of  Foot. — ^This  ulcer  follows  a  localized  necrosis  of 
the  foot,  which  is  supposed  to  be,  in  part,  at  least,  the  consequence  of 
vasomotor  disturbances,  to  which  are  added  impediments  to  the  circulation 
and  frequently  infection  with  pathogenic  microorganisms.  This  ulcer  is 
remarkable  for  the  regularity  of  its  outline,  looking  as  though  a  piece  had 
been  ciit  out  with  a  punch.  The  defect  corresponds  to  the  shape  of  the  de- 
tached necrosed  tissue.  The  necrosis  affects  all  of  the  tissues  of  the  part  in 
which  it  occurs,  not  even  sparing  the  bones  and  articulations  of  the  foot. 
The  dissections  of  Duplay,  Morat,  Fischer,  and  others  leave  no  doubt  that 
this  strange  ulcer  originates  from  necrosis  following  degeneration  of  the 
nerves  of  the  affected  region.  Infection  with  pus-microbes  follows  the 
necrosis:   an  occurrence  which  renders  the  treatment  more  intractable. 

Ergotin. — One  of  the  effects  of  chronic  ergot  intoxication  is  sym- 
metrical dry  gangrene.  Bread  made  of  flour  containing'  ergot  has  not  in- 
frequently occasioned,  in  Europe,  fatal  epidemics,  usually  attended  with  dry 
gangrene.  As  before  stated,  the  gangrene  following  the  prolonged  admin- 
istration of  this  drug  is  either  the  result  of  a  chronic  angiospasm  or  of  a 
paralytic  effect  of  the  drug  on  the  peripheral  nerves. 

Prognosis. — The  prognosis  in  a  case  of  gangrene  should  be  based  on  the 
etiology,  location,  and  extent  of  the  disease  which  caused  the  gangrene. 
The  existence  of  complications  must  also  be  taken  into  careful  consideration. 
Acute,  rapidly-spreading  gangrene,  irrespective  of  the  causes  which  may 
produce  it,  must  always  be  considered  as  an  exceedingly  grave  condition. 
Mycotic  progressive  gangrene,  with  and  without  emphysema,  unless  treated 
early  and  heroically,  proves  fatal  almost  without  exception,  death  resulting 
from  septicemia.     Gangrene  following  obliteration  of  the  principal  artery 


PATHOLOGICAL    AND    CLINICAL    VAKIETIES    OF    NECEOSIS.  215 

of  a  limb  would  result  in  death,  in  the  majority  of  cases,  unless  a  fatal  sepsis 
is  jDrevented  by  early  amputation.  Necrosis  of  the  entire  or  greater  part  of 
important  internal  organs  is  incompatible  with  life  from  the  greatly  dimin- 
ished or  completely  suspended  function  of  the  affected  organs.  The  prog- 
nosis, so  far  as  life  is  concerned,  in  eases  of  senile  gangrene,  is  rendered  ex- 
ceedingly grave  when  the  gangrene  spreads  rapidl}'',  in  consequence  of  an 
ascending  arterial  thrombosis,  or  thrombophlebitis,  and  life  is  in  imminent 
danger  when  the  gangrene  due  to  diminished  blood-supply  is  complicated  by 
a  rapidly-spreading  suppurative  inflammation,  or  if  septic  intoxication  arise 
from  invasion  of  the  moist  necrosed  tissue  with  putrefactive  bacteria.  The 
general  condition  and  age  of  the  patient  play  an  important  part  in  arriving 
at  correct  prognostic  conclusions.  Patients  debilitated  from  antecedent 
acute  or  chronic  disease  are  in  greater  peril  of  life  than  robust,  healthy  per- 
sons whose  circulation  and  tissue-resistance  have  not  been  impaired.  In- 
fants and  the  aged  succumb  to  gangrene  more  readily  than  young  adults 
and  persons  in  middle  life,  although  the  gangrene  may  have  resulted  from 
the  same  causes,  reached  the  same  extent,  and  involved  the  same  parts. 
Gangrene  of  some  important  organ,  as  the  lungs  or  intestines,  is  more  dan- 
gerous to  life  than  peripheral  gangrene.  The  coexistence  of  complications, 
such  as  diabetes,  Bright's  disease,  tuberculosis,  valvular  disease  of  the  heart, 
and  cirrhosis  of  the  liver  will  influence  the  prognosis  correspondingly. 

Treatment. — The  prophylactic  treatment  includes  such  measures,  me- 
dicinal, dietetic,  and  otherwise,  as  are  calculated  to  improve  the  blood-sup- 
ply of  the  part  threatened  with  gangrene,  and,  if  this  has  occurred  or  is 
inevitable,  to  prevent  putrefaction  of  the  dead  tissues.  In  threatened  gan- 
grene from  obstruction  of  the  main  artery  of  a  limb,  the  establishment  of 
collateral  circulation  must  be  aided  by  placing  the  limb  in  a  horizontal  or 
slightly-elevated  position,  and  by  the  external  application  of  dry  heat.  In 
the  aged  suffering  from  premonitory  peripheral  symptoms  of  gangrene,  its 
actual  occurrence  can  often  be  postponed  by  massage,  rubbing  the  limb  from 
the  toes  toward  the  body  for  ten  or  fifteen  minutes  twice  dail}^,  and  by  the 
avoidance  of  all  causes  which  would  bring  about  stasis  in  the  enfeebled 
blood-vessels.  The  minutest  lesions  of  the  skin — as  abrasions,  corns,  bun- 
ions, ulcers,  etc. — should  receive  careful  attention  in  all  persons  the  sub- 
jects of  a  feeble  circulation,  as  they  frequently  are  the  starting-points  of 
gangrenous  inflammation.  Diabetic  persons  are  exceedingly  liable  to  be  at- 
tacked with  gangrene  after  the  slightest  operation  or  the  most  insignificant 
iujury,  and  on  this  account  it  is  advisable  to  examine  the  urine  before  un- 
dertaking an  operation  on  persons  presenting  the  faintest  evidence  of  this 
disease.  As  most  forms  of  gangrene  are  of  mycotic  origin,  all  infection-atria 
should  be  protected  against  infection  from  without  by  thorough  aseptic 
precautions.    The  prevention  of  decubitus  has  already  been  referred  to,  and 


216  PEINCIPLES    OF    SUEGEEY. 

here  will  be  only  mentioned  the  necessity  of  securing  for  the  necrosed  tis- 
sues an  aseptic  condition  by  rigid  cleanliness  and  antiseptic  measures  in 
cases  where  the  necrosis  has  occurred,  or  where  it  cannot  be  prevented.  In 
moist  gangrene  the  prevention  of  putrefaction  is  a  most  difficult  task.  Where 
gangrene  of  this  type  has  occurred  or  is  anticipated,  the  whole  surface  far 
beyond  the  area  involved  or  threatened  should  be  rendered  aseptic  in  the 
same  manner  as  in  the  preparation  for  an  operation,  and  the  parts  protected 
as  far  as  possible  against  invasion  with  putrefactive  bacteria  by  an  absorbent 
antiseptic  dressing.  A  few  layers  of  gauze  and  a  thick  compress  of  salicylated 
cotton  answer  an  excellent  purpose  in  meeting  this  indication.  If  gangrene 
with  putrefaction  has  occurred,  the  etiological  indications  for  local  treat- 
ment are  best  met  by  multiple  incisions  through  the  necrosed  tissues  and 
undermined  skin  and  the  application  of  a  compress  wrung  out  of  a  1-per- 
cent, solution  of  acetate  of  aluminum.  If  the  f cetor  is  intense,  Labarraque's 
solution  of  chlorinated  soda,  properly  diluted,  answers  an  admirable  purpose. 
In  gangrene  with  partial  separation  of  the  slough  and  considerable  under- 
mining, permanent  irrigation  with  either  of  these  preparations  answers  the 
best  purpose.  All  patients  suffering  from  gangrene  are  debilitated  from 
antecedent  or  concomitant  causes,  and  consequently  are  badly  affected  by 
any  form  of  the  so-called  antiphlogistic  or  sedative  treatment.  Fever  is 
always  the  result  of  the  entrance  of  septic  material,  and  should  therefore  not 
be  treated  by  antipyretics,  but  by  local  measures  directed  toward  the  pri- 
mary cause.  Quinine  in  sedative  doses  does  more  harm  than  good.  Vera- 
trum  viride,  tartar  emetic,  and  the  innumerable  chemical  substances  which 
have  recently  been  so  much  lauded  as  antif  ever  remedies  should  never  be  pre- 
scribed in  the  treatment  of  fever  attending  necrosis.  The  patient's  strength 
must  be  supported  from  the  beginning  by  a  liberal  diet  and  the  use  of  stim- 
ulants. If  the  heart's  action  is  feeble,  digitalis  can  be  given  with  benefit. 
Quinine  in  tonic  doses  is  indicated.  Anorexia  not  dependent  on  high  fever 
calls  for  some  one  or  a  combination  of  bitter  tonics.  The  part  affected  must 
be  placed  at  rest  and  in  a  position  most  favorable  for  the  passage  of  the 
blood  through  the  capillaries. 

The  question  of  removal  of  gangrenous  tissue  and  the  amputation  of  a 
gangrenous  limb  should  receive  thoughtful,  conscientious  consideration  be- 
fore an  operation  is  undertaken.  The  favorable  results  which  have  followed 
the  operative  removal  of  a  gangrenous  part  after  the  line  of  demarcation  had 
formed,  and  the  great  mortality  of  operations  undertaken  without  such  a 
positive  indication,  have  led  many  good  surgeons  to  advise  postponement 
of  all  operative  procedure  until  nature  has  indicated  the  site  of  operation. 
This  conservative  rule,  however,  is  incompatible  with  the  teachings  of  mod- 
ern surgery.  We  know  that  death  in  cases  of  rapidly-spreading  gangrene 
is  caused  by  septic  intoxication.    We  also  know  that  the  cause  of  the  septic 


PATHOLOGICAL   AJv'D    CLINICAL    VAEIETIES    OF    NECEOSIS.  217 

intoxication  inhabits  the  dead  tissue,  and  we  are  also  aware  that  the  exten- 
sion of  the  immediate  canse  of  gangrene  (vessel-obstruction),  ascending 
thrombosis  in  the  arteries,  and  ascending  thrombophlebitis  in  the  veins  pro- 
ceed from  the  gangrenous  part.  In  view  of  these  facts,  the  delay  of  operative 
measures  in  the  treatment  of  gangrene  until  the  line  of  demarcation  has  been 
established  would  be  to  wait  for  something  which,  in  the  most  urgent  cases, 
never  occurs.  In  the  absence  of  symptoms  indicating  danger  from  septi- 
caemia it  is  not  only  advisable,  but  absolutely  necessary,  to  postpone  the  oper- 
ative removal  of  the  gangrenous  part  until  nature  locates  the  site  for  the 
operation  by  the  formation  of  the  line  of  demarcation.  In  aseptic  dry  gan- 
grene involving  parts  where  no  formal  operation  is  necessary  to  secure  a 
favorable  healing,  later  spontaneous  elimination  should  be  waited  for,  and 
after  separation  of  the  necrosed  tissue  the  granulating  surface  is  treated  in 
the  usual  manner.  In  moist  gangrene  the  dead  tissue  is  removed  as  soon  as 
partial  separation  has  taken  place  by  dividing  with  scissors  the  more  re- 
sistant structures,  as  fascia  and  tendons,  after  which  the  resulting  wound  is 
treated  upon  antiseptic  principles.  In  gangrene  of  the  extremities  amputa- 
tion can  be  done  safely,  and  with  good  prospects  of  success,  as  soon  as  the 
line  of  demarcation  has  formed.  In  such  cases  it  is  necessary  to  remove  as 
little  as  possible  of  the  healthy  tissue  by  carrying  the  incisions  in  such  a  man- 
ner as  to  leave  flaps  composed  of  healthy  tissue  simply  long  enough  to  cover 
the  bone.  No  typical  operation  should  be  adopted,  as  the  flaps  must  be  made 
not  in  conformity  with  any  text-book  rules,  but  the  condition  of  the  limb. 
If  the  patient  is  febrile,  and  the  character  of  the  fever  indicates  as  its  origin 
the  gangrenous  part,  delay,  to  say  the  least,  is  attended  by  increased  danger 
of  extension  of  the  gangrene,  and  death  from  septicaemia.  Such  cases  fare 
best  at  the  hands  of  j)rudent,  but  courageous,  surgeons.  Procrastination  in 
such  cases  is  a  sign  of  timidity  or  ignorance.  What  is  to  be  done  must  be 
done  at  once.  The  patient  and  friends  must  be  made  acquainted  with  the 
dangers  incident  to  delay,  and  the  only  prospect  of  recovery  by  early  amputa- 
tion. Consultation  with  one  or  more  of  the  neighboring  physicians  is  an  ab- 
solute necessity  in  such  cases.  Fortified  by  a  fair  imderstanding  with  the 
patient  and  his  friends,  supported  by  the  advice  and  counsel  of  one  or  more 
of  his  colleagues,  no  surgeon  need  fear  to  follow  the  dictates  of  his  conscience, 
even  in  the  most  unpromising  cases.  The  distinguished  Hueter  related  sev- 
eral cases  where  early  amputation  saved  the  lives  of  patients  who  were  in 
stupor  from  the  efl^ects  of  septic  intoxication  to  such  an  extent  that  an  anaes- 
thetic was  unnecessary.  Early  amputation  should  be  urged  and  done  in  all 
cases  where  life  is  placed  in  Jeopardy  from  absorption  of  septic  material  from 
the  gangrenous  part.  .  The  results  after  amputation  under  such  circum- 
stances will  always  remain  uncertain,  because  in  many  instances  fatal  general 
infection  occurs  soon  after  the  development  of  the  first  general  symptoms, 


218  PRINCIPLES    OF    SURGERY. 

and  the  local  infection  frequently  extends  to  the  site  of  operation,  rendering 
a  recurrence  of  gangrene  in  the  stump  a  great  probability.  Amputation 
should  be  done,  as  near  as  possible,  through  healthy  tissue.  Much  gooa 
judgment  is  necessary  to  determine  this  location.  It  is  safe  to  maintain  that, 
the  more  acute  the  attack,  the  more  distant  should  the  amputation  be  made 
from  the  apparent  boundary-line  of  the  gangrene.  In  gangrene  from  ob- 
struction of  a  large  blood-vessel  and  in  gangrene  attended  by  ascending 
thrombophlebitis,  arterial  thrombosis,  or  both  of  these  conditions,  the  line 
of  amputation  should  invariably  fall  through  a  point  where  the  vessels  are 
patent;  otherwise,  a  recurrence  of  the  disease  is  almost  sure  to  take  place. 
The  concensus  of  opinion  of  modern  surgeons  is  in  favor  of  high  amputation 
for  diabetic  gangrene;  that  is,  in  gangrene  of  the  foot,  amputation,  as  a  rule, 
should  be  made  above  the  knee-joint.  Before  the  amputation  is  made  the 
part  to  be  removed  should  be  enveloped  in  towels  wrung  out  in  an  antiseptic 
solution  for  the  purpose  of  preventing  contamination  of  the  wound  with 
septic  material  from  the  dead  tissue.  It  is  almost  needless  to  mention  that 
Esmarch^s  elastic  bandage  should  never  be  used,  as  by  its  application  septic 
material  might  be  forced  into  the  circulation.  The  limb  should  be  rendered 
as  nearly  bloodless  as  possible  by  holding  it  for  a  few  minutes  in  a  perpen- 
dicular position,  when  an  elastic  constrictor  is  applied  some  distance  above 
the  point  selected  for  the  amputation.  In  septic  patients  the  parenchyma- 
tous oozing  sometimes  is  difficult  to  control,  but  is  managed  most  success- 
fully by  keeping  the  limb  in  the  elevated  position,  and  by  making  surface- 
pressure  with  a  large,  flat  sponge  or  gauze  compress  wrung  out  in  hot  water. 
As  most  of  these  patients  are  prostrated  from  the  effects  of  the  disease,  they 
are  liable  to  suffer  from  shock,  and  measures  should  be  resorted  to  to  pre- 
vent this  complication,  or,  at  least,  diminish  its  severity.  For  this  purpose 
a  subcutaneous  injection  of  ^/loo  "to  -/loo  grain  of  atropia  with  ^/g  grain  of 
morphia  or  ^/go  grain  of  strychnia  is  administered  before  the  anaesthetic  is 
given.  Two  ounces  of  whisky  or  the  same  amount  of  brandy  should  be 
given  at  the  same  time  by  the  stomach,  or,  preferably,  per  rectum.  Ether 
is  preferable  to  chloroform  in  these  cases  as  an  angesthetic.  After  the  oper- 
ation the  most  careful  after-treatment  is  required  to  meet  possible  emer- 
gencies. Shock  is  treated  by  alcoholic  stimulants,  camphorated  oil,  musk, 
strychnia,  and  coffee,  and  in  grave  cases  by  subcutaneous  or  intravenous  in- 
fusion of  normal  salt  solution.  If  the  stomach  is  irritable,  brandy,  whisky, 
or  coffee  is  administered  by  the  rectum.  Camphorated  oil  or  musk  is  given 
hypodermically  every  half-hour  until  the  patient  reacts.  External  heat  is 
useful  in  relieving  congestions  of  internal  organs  and  in  stimulating  the 
action  of  the  heart.  Amputation  wounds  made  through  tissues  that  are 
not  positively  known  to  be  aseptic  should  always  be  drained;  this  is  the 
more  necessary  if  the  soft  tissues  are  oedematous.     Should  the  tissues  at 


PATHOLOGICAL   AND    CLINICAL    VARIETIES    OF    NECEOSIS.  219 

the  seat  of  amputation  not  present  a  satisfactory  appearance,  it  is  advisable 
to  go  up  higher,  more  especially  if  the  vessels  are  obstructed  by  a  throm- 
bus. The  fate  of  the  patient  is  decided  within  a  few  days  after  the  am- 
putation. The  most  favorable  symptom  is  a  reduction  of  the  tempera- 
ture to  normal  within  a  few  hours  after  the  operation,  which  will  be  the 
case  if  the  fever  has  been  caused  by  a  septic  intoxication.  With  the  re- 
moval of  the  tissues  which  furnished  the  toxic  substances  and  the  elimi- 
nation of  these  through  the  secretory  organs,  the  septic  symptoms  sub- 
side; and  if  the  patient  have  enough  strength  left  to  carry  him  over  the 
immediate  effects  of  the  operation,  the  prospects  of  recovery  are  good. 
If  the  patient  is  the  subject  of  a  progressive  sepsis,  the  amputation,  in 
all  probability,  will  prove  powerless  as  a  life-saving  measure,  as  the  mi- 
crobes which  have  reached  the  circulation  reproduce  themselves  with  great 
rapidity,  and  death  from  this  cause  results  within  a  few  hours  to  several 
days.  Prompt  improvement  soon  after  the  operation,  with  recurrence  of 
febrile  symptoms  in  a  few  days,  indicates  the  occurrence  of  gangrene  in  the 
stump.  Sueh  s3rmptoms  demand  a  change  of  dressing.  If  gangrene  is  pres- 
ent all  sutures  are  removed  and  a  thorough  local  disinfection  practiced,  after 
which  the  stump  should  be  treated  by  constant  antiseptic  irrigation.  Ee- 
amputation  at  this  time  would,  in  all  probability,  prove  fatal,  and  reliance 
on  local  disinfection,  combined  with  the  use  of  stimulants  and  tonics,  is 
advised  with  a  feeble  hope  that  these  measures  may  become  the  means  of 
limiting  the  extension  of  the  disease  and  of  supporting  the  heart's  action 
until  the  line  of  demarcation  is  established,  when  the  surgeon's  services 
are  again  required  to  assist  Nature's  efforts  in  the  elimination  of  the  dead 
tissues.  In  noma  and  hospital  gangrene  the  infected  tissues  are  removed 
with  the  sharp  spoon,  and  after  thorough  antiseptic  irrigation  the  actual 
cautery  is  applied,  and  the  further  management  of  the  wound  is  the  same 
as  in  case  of  infected  wounds  from  other  causes.  Chlorinated  water  and 
a  solution  of  bromine  are  excellent  preparations  after  the  primary  disin- 
fection and  cauterization  in  the  treatment  of  these  diseases. 


CHAPTEE  IX. 

SUPPUKATION. 
BACTEEIOLOGICAL    CAUSES    AND    HISTOGENESIS    OF    SIJPPURATION. 

SuppuEATiON  is  the  most  frequent  termination  of  acute  inflammation. 
Inflammation  terminating  in  the  formation  of  pus  is  called  suppurative, 
both  on  account  of  its  etiology  and  the  nature  of  the  inflammatory  product. 
Suppuration  is  the  process  by  which  the  morphological  elements  of  the 
inflammatory  product,  the  leucocytes,  and  embryonal  cells  are  converted 
into  pus-corpuscles.  Suppurative  inflammation  is  caused  by  the  action 
upon  the  tissues  of  specific  microorganisms,  the  pus-microbes,  and  the 
transformation  of  leucocytes  and  embryonal  cells  into  pus-corpuscles  is 
accomplished  by  the  same  cause.  The  brilliant  results  which  have  been 
obtained  by  the  antiseptic  treatment  of  wounds  made  it  exceedingly  prob- 
able that  all  wound-infective  diseases  are  caused  by  living  microorganisms. 
The  probability  was  increased  when  Koch,  in  1879,  showed  the  direct  con- 
nection existing  between  certain  traumatic  infective  diseases  in  animals 
and  the  never-absent  definite  microorganisms.  It  requires  no  longer  any 
arguments  to  show,  at  this  time,  that  all  inflammatory  wound  complica- 
tions, among  them  suppuration,  are,  without  exception,  caused  by  the  in- 
troduction into  the  tissues  of  speciflc  pathogenic  microbes.  Etiologically, 
most  of  the  purulent  processes  constitute  more  of  a  unity  than  was  for- 
merly believed,  and  the  clinical  varieties  are  mostly  determined  by  the 
intensity  of  the  infection,  the  manner  of  localization,  and  the  degree  of 
resistance  possessed  by  the  tissues.  The  most  conclusive  evidence  of  the 
correctness  of  this  assertion  is  furnished  by  the  fact  that  the  same  strepto- 
coccus which  produces  a  simple  abscess  is  likewise  the  most  frequent  cause 
of  progressive  gangrene,  and  of  that  most  grave  form  of  suppuration: 
pyaemia. 

I.    HISTORY    OF    MICROBIC    ORIGIN    OF    SUPPURATION. 

As  in  the  case  of  nearly  all  infective  diseases,  years  before  the  specific 
pus-microbes  were  discovered  living  organisms  were  found  in  jjus  and  de- 
scribed, and  were  believed  to  be  the  essential  cause  of  suppuration.  More 
than  thirty  years  ago  Ivlebs  discovered,  in  the  tubuli  uriniferi  in  cases 
of  pyelonephritis  following  suppurative  cystitis,  between  the  pus-cells, 
small,  round  cocci,  which  he  believed  produced  the  infection.  In  1872 
the  same  author  published  the  result  of  his  researches,  during  the  Franco- 
Prussian  War,  on  septic-wound  diseases.     In  this  work  he  again  referred 

(220) 


HISTORY    OF    MICEOBIC    OEIGIX    OF    SUPPURATION.  221 

to  the  microorganisms  which  he  had  previously  described,  and  showed 
that  they  existed  in  the  tissues  and  organs — ^the  seat  of  suppurative  in- 
flammation— before  pus  had  formed.  He  also  showed  how  these  microor- 
ganisms enter  the  circulation  and  become  the  direct  cause  of  patho- 
logical conditions  in  distant  organs.  Even  at  that  time  he  placed  great 
stress  on  the  fact  that,  as  long  as  the  cocci  remained  only  in  the  tissues 
at  the  point  of  infection,  they  produce  only  local  inflammation  or  necrosis, 
but  as  soon  as  they  enter  the  circulation  fever  and  other  symptoms  of 
general  septic  infection  follow. 

Ogston,  the  discoverer  of  pus-microbes,  published  the  results  of  his 
observations  and  researches  in  1881.  This  patient  investigator  examined 
the  pus  of  69  abscesses  for  microorganisms,  and  found  in  17  of  them  a 
chain  coccus  (streptococcus),  in  31  cocci  which  arranged  themselves  in 
groups  which  resemble  a  bunch  of  grapes  (staphylococcus),  and  in  16  both 
of  these  forms  were  present.  In  cold  abscess  he  was  unable  to  find  either 
of  these  microorganisms.  He  also  ascertained  that  these  two  forms  of 
microbes  differed  in  their  manner  of  diffusion  in  and  action  on  the  tissues, 
as  the  streptococcus,  following  the  lymph-channels  and  connective-tissue 
spaces,  was  seen  to  be  the  cause  of  diffuse  suj)purative  processes,  while  the 
staphylococcus  was  found  by  him  only  in  abscesses  which  were  circum- 
scribed. 

Eosenbach  took  up  the  Avork  where  Ogston  left  it,  and,  as  the  fruit 
of  a  number  of  years  of  patient  study  and  research,  published  his  classical 
work  in  1884  ("Microorganismen  bei  den  Wundinfections  Krankheiten  des 
Menschen,"  Wiesbaden,  1884).  This  work  must  serve  as  a  basis  for  all 
future  research  on  suppurative  inflammation.  Eosenbach  availed  himself 
of  the  advantages  offered  by  an  improved  technique  in  bacteriological 
research,  cultivated  the  different  pus-microbes  upon  solid  nutrient  media, 
and  pointed  out  the  difference  in  the  macroscopical  appearances  of  the 
cultures  of  the  different  kinds  of  pus-microbes,  which  enabled  him  to  dif- 
ferentiate between  them  by  the  naked-eye  appearances  of  the  cultures 
upon  the  different  nutrient  substances.  He  discovered  the  staphylococcus 
pyogenes  aureus,  the  micrococcus  pyogenes  tenuis,  and  three  kinds  of 
bacillus  saprogenes. 

Passet  should  be  mentioned  next  in  the  long  list  of  distinguished 
names  of  original  investigators  who  have  made  the  bacteriology  of  sup- 
puration a  special  study.  He  discovered  and  described  the  staphylococcus 
citreus  and  the  staphylococcus  cereus  albus  and  flavus,  and  from  a  peri- 
rectal abscess  he  cultivated  the  bacillus  pyogenes  foetidus.  The  strepto- 
coccus which  he  found  he  maintained  was  different  from  the  one  described 
by  Eosenbach,  as  it  resembled  more  closely  the  streptococcus  of  erysipelas, 
but  this  claim  has  not  been  substantiated  b}^  subsequent  investigations. 


222  PEINCIPLES    OF    SUEGERY. 

The  bacillus  pyocyaneus  was  described  by  Gessard  and  Charrin.  The 
gonococcus,  the  specific  microbe  of  gonorrhoea,  was  discovered  by  ISTeisser, 
in  1879.  In  our  own  country  the  microorganisms  of  pus  have  been  studied 
by  such  men  as  Sternberg,  Osier,  Councilman,  Welch,  Ernst,  and  Park. 

II.    INDIRECT    CAUSES    OF    SUPPURATION. 

Inflammation  produces  in  the  tissues  conditions  which  must  be  re- 
garded as  indirect  causes  of  suppuration.  These  conditions  favor  the  sup- 
purative process  by  bringing  the  histological  elements  of  the  inflammatory 
product  in  a  j)osition  or  relation  to  the  blood-vessels  which  impairs  or  sus- 
pends their  nutrient  supply.  In  acute  inflammation  the  connective-tissue 
spaces  become  crowded,  in  a  short  time,  with  the  corpuscular  elements  of 
the  blood,  which,  by  their  presence  in  such  great  number,  cause  dilata- 
tion of  these  spaces  and  pressure  upon  the  adjacent  capillary  vessels, 
which  often  result  in  complete  stasis  and  consequently  arrest  of  blood- 
supply.  In  consequence  of  suspended  nutrition  arising  from  vascular  ob- 
struction, the  leucocytes  undergo  coagulation-necrosis  and  lose  their  power 
of  resistance  to  the  action  of  pathogenic  microorganisms.  If  inflammation 
attack  the  fixed  tissue-cells  with  an  intensity  short  of  producing  necrosis, 
the  cells  proliferate  and  the  embryonal  cells  thus  produced  constitute  an- 
other source  of  histological  elements  of  the  infiammatory  product.  If  the 
cells  are  produced  in  excess  of  the  capacity  of  the  inflamed  part  to  supply 
them  with  new  blood-vessels,  the  local  antemia  thus  created  places  them 
in  the  same  unfavorable  condition  as  the  leucocytes  in  the  crowded  con- 
nective-tissue spaces,  and  they  are  exposed  to  the  same  risk  of  death  from 
malnutrition.  If,  as  the  result  of  rapid  tissue-proliferation  and  local 
ischgemia,  the  embryonal  cell  become  completely  detached  from  the  matrix 
which  produced  it,  it  is  placed  in  the  worst  condition,  so  far  as  its  vitality 
and  vegetative  capacities  are  concerned,  and  it  readily  succumbs  to  the 
deleterious  action  of  the  pus-microbes.  It  can  be  set  down  as  a  rule  that 
all  conditions,  local  or  general,  which  impair  cell-nutrition  favor  the  sup- 
purative process.  Suppuration  in  inflammatory  foci  is  always  observed 
first  where  cell-nutrition  is  most  impaired,  hence  in  the  primary  inflam- 
matory product  among  the  leucocytes  most  distant  from  capillary  vessels, 
and  among  embryonal  cells  that  have  become  isolated  or  occupy  a  place 
most  remote  from  the  vascular  supply. 

III.    DIRECT    CAUSES    OF    SUPPURATION". 

Clinical  suppuration  is  caused  by  the  action  of  pus-microbes  or  their 
toxins  on  the  leucocytes  and  embryonal  cells,  by  which  these  cells,  the 
mor^ohological  elements  of  the  inflammatory  product,  are  converteci  into 


DIEECT    CAUSES    OF    SUPPUEATION.  323 

pus-corpuscles.    A  number  of  investigators  maintain  that  suppuration  can 
be  produced  artificially  in  animals  by  injecting  into  the  tissues  certain 

Chemical  Pyogenic  Substances.  —  The  substances  which  have  been 
found  to  possess  the  property  of  exciting  suppurative  inflammation  are 
metallic  mercury,  turpentine,  and  croton-oil.  Councilman  introduced 
turpentine  and  croton-oil  in  aseptic  glass  capsules  into  the  subcutaneous 
connective  tissue  of  animals  under  strict  aseptic  precautions,  and,  after 
the  wound  had  healed  and  the  capsules  had  become  encysted,  ruptured 
them  subeutaneously.  He  found  that  both  of  these  substances  caused  a 
circiimscribed  suppuration.  Uskof!  claimed  that  a  considerable  quantity 
of  indifferent  substances,  such  as  milk,  olive-oil,  etc.,  if  injected  subeu- 
taneously in  animals,  either  at  once  or  by  repeating  the  injection  from 
time  to  time,  caused  suppuration,  and  that  turpentine  administered  in 
the  same  manner  always  acted  as  a  pyogenic  agent.  Orthmann,  under 
Eosenbach's  supervision,  repeated  Uskoff's  experiments,  and,  by  resorting 
to  more  strict  aseptic  precautions,  could  not  verify  the  correctness  of 
his  conclusions  in  reference  to  the  pus-producing  properties  of  indifferent 
substances.  His  experiments  with  croton-oil,  turpentine,  and  metallic 
mercury  always  resulted  in  inflammation  and  suppuration.  G-rawitz  and 
de  Bary  ascertained  that  croton-oil,  when  injected  in  small  quantities  into 
the  subcutaneous  tissues  of  rabbits,  caused  a  serous  transudation  or  a 
fibrinous  exudation,  while  larger  doses  acted  as  a  caustic,  and  were  only 
occasionally  followed  by  suppuration.  If  they  injected  a  mixture  of  pus- 
microbes  and  croton-oil  it  always  was  followed  by  the  formation  of  pus. 
They  maintained  that  certain  chemical  substances,  used  in  a  definite  de- 
gree of  concentration,  injected  into  the  subcutaneous  tissues  of  animals, 
prepared  the  tissues  for  the  growth  of  the  pus-microbes.  From  a  later 
series  of  experiments  Grawitz  became  more  firmly  convinced  that  aseptic 
turpentine,  used  in  sufficient  quantities,  always  causes  a  suppurative  in- 
flammation in  the  connective  tissue.  Inoculations  of  different  nutrient 
media  with  pus  produced  by  turpentine  showed  that  it  contained  no  pus- 
microbes.  He  also  determined  that  such  chemical  pus  had  a  destructive 
effect  on  pus-microbes.  This  action  of  sterile  pus  he  attributes  not  to 
the  presence  of  toxins,  but  to  the  action  of  its  albuminous  constituents.  ■ 
His  experiments  also  lead  to  the  important  observation  that  when  gelatin 
cultures  are  oversaturated  with  albumin,  or  peptone,  pus-microbes  cease  to 
multiply.  A  number  of  years  ago  Eosenbach  made  a  series  of  experi- 
ments which  has  convinced  him  that  the  chemical  pyogenic  substances 
which  have  been  mentioned,  when  injected  into  the  tissues  of  animals, 
cause  suppuration  independently  of  the  presence  of  pus-microbes.  Eeichel 
has  made  numerous  experiments  on  animals  by  injecting  gradually- 
increasing  doses  of  pus-microbes  or  their  toxins  into  the  peritoneal  cavity. 


234  PRINCIPLES    OF    SUEGERY. 

and  lias  proved  that  a  certain  degree  of  immunity  is  procured,  by  this 
treatment,  to  infection  with  large  doses  of  pus-microbes,  which,  in  other 
animals  not  thus  treated,  produced  fatal  suppurative  peritonitis.  He 
maintains  that  suppuration  caused  by  microbes  and  their  chemical 
products  is  in  so  far  different  that  the  former  may  produce  metastases, 
while  the  suppuration  caused  exclusively  by  toxins  always  remains  local. 
Buchner  has  recently  demonstrated,  by  experiments,  that  sterilized  cult- 
ures of  a  long  list  of  bacteria — seventeen  species  tested — -give  rise  to  sup- 
puration when  injected  into  the  subcutaneous  tissues.  The  same  author 
has  also  shown  that  the  pyogenic  action  of  these  cultures  is  due  to_  the 
dead  microbes,  as  injections  of  the  clear  filtrate  yielded  only  negative  re- 
sults. The  toxalbumin  of  staphylococcus  aureus  killed  rabbits  and  guinea- 
pigs  within  a  few  days,  and  in  some  cases  at  the  end  of  twenty-four  hours. 
The  post-mortem  appearances  were  necrosis  or  purulent  infiltration  at  the 
point  of  injection,  with  external  changes  which  were  characteristic  of 
inflammation. 

Among  those  who,  from  their  own  experimental  work,  have  come  to 
diametrically  opposite  conclusions  can  be  mentioned  Scheuerlen,  Euiys, 
j^athan,  and  Biondi. 

If  we  consider  for  a  moment  how  very  difficult  it  is,  in  experimenting 
on  animals  with  indifferent  substances  and  chemical  irritants,  to  procure 
for  the  seat  of  injection  a  perfectly  aseptic  condition,  it  is  not  at  all  diffi- 
cult to  conceive  that  opinions  still  differ  in  regard  to  the  immediate  and 
essential  cause  of  suppuration.  Taking  it  for  granted  that  certain  chem- 
ical.pyogenic  substances,  when  injected  in  sufficient  quantities  into  the 
tissues  of  animals,  have  the  power  to  produce  suppuration,  inflammation 
and  suppuration  produced  in  such  a  manner  do  not  represent  clinically 
suppurative  affections.  Neither  the  inflammation  nor  the  suppuration 
following  such  experiments  are  progressive  in  their  character.  The  chem- 
ical substances  produce  inflammation  over  an  area  which  corresponds  with 
the  extent  of  its  diffusion,  and  the  cellular  elements  of  the  inflammatory 
product  are  converted  into  pus-corpuscles  by  the  destructive  action  of  the 
substance  on  their  protoplasm.  The  whole  course  of  the  artificial  affec- 
tion remains  aseptic  throughout,  and  the  pus  which  is  produced  is  aseptic 
and  sterile, — not  clinical,  but  chemical,  pus. 

In  suppuration,  as  we  see  it  at  the  bedside,  the  direct  cause  which 
produced  it  multiplies  in  the  tissues;  hence  its  tendency  to  become  pro- 
gressive, and  from  the  pus  which  is  produced  the  immediate  and  essential 
cause — the  pus-microbes — can  be  cultivated.  Practically,  in  man,  the  oc- 
currence of  suppuration  from  the  action  of  pyogenic  chemical  substances 
would  be  possible  only  on  the  surface  of  the  body. 

Pus-microbes. — That  the  pus-microbes  are  the  immediate  and  ess&ntial 


DIEECT    CAUSES    OE    SUPPUKATION. 


225 


cause  of  suppu7'ative  inflammation  and  pus-formation  has  been  well  estab- 
lished by  clinical  observation  and  experimentation.  Clinical  experience  dur- 
ing the  last  thirty  years  has  shown  beyond  all  do-ubt  that  suppuration  in 
wounds  can  be  prevented  by  measures  which  are  calculated  to  remove,  de- 
stroy, and  exclude  pathogenic  microorganisms  from  without. 

Eosenbach  discovered  that,  in  dogs  and  rabbits,  a  small  quantity  of  a 
pure  culture  of  the  staphylococcus  pyogenes  aureus  injected  under  the 
skin  produced  a  most  violent  suppurative  inflammation;  cultures  of  the 
staphylococcus  pyogenes  albus  had  the  same  effect.  Cultures  of  the  strep- 
tococcus pyogenes  produced  only  slight  inflammation  in  rabbits  while  they 
proved  very  fatal  in  mice. 

Passet  procured  a  pure  culture  of  the  staphylococcus  pyogenes  aureus, 
about  the  size  of  a  pea,  which  had  been  grown  upon  potato,  and  mixed  it 


Pig.  85. — Vertical  Section  through  a  Subcutaneous  AbscesS  Caused  by  Inoculation 
with  Staphylococci  in  the  Rabbit,  Forty-eight  Hours  after  Infection;  Margin  toward  the 
Normal  Tissue.     (Baumgarten.) 


with  1  cubic  centimetre  of  distilled  water.  Of  this  mixture  he  injected 
under  the  skin  of  a  mouse  0.1  cubic  centimetre;  the  animal  recovered.  An- 
other mouse  was  treated  in  the  same  manner,  but  0.4  cubic  centimetre  of  a 
liquefied-gelatin  culture  was  used,  and  this  animal  died  in  eighteen  hours. 
Cocci  were  found  in  the  blood.  In  rabbits  and  dogs  a  subcutaneous  injec- 
tion of  1  cubic  centimetre  of  liquid-gelatin  culture  of  the  aureus  usually 
produced  an  abscess  at  the  point  of  inoculation.  If  the  dose  was  increased 
to  5  cubic  centimetres  of  the  same  culture  the  animals  died  in  from 
eighteen  to  twenty  hours.  At  the  same  time  a  local  inflammation  was 
found  at  the  site  of  inoculation.  In  all  of  the  fatal  cases  the  pus-microbe 
was  found  in  the  blood.  Of  the  culture  of  the  streptococcus  pyogenes  it 
was  found  necessary  to  inject  a  considerable  quantity  in  order  to  produce 
suppuration.     Liquefied-gelatin  cultures  of  the  staphylococcus  pyogenes 


236  PEINCIPLES    OF    SUEGEKY, 

aureus  and  albus^  in  doses  of  1  cubic  centimetre,  injected  into  the  abdom- 
inal cavity  of  rabbits,  were  well  tolerated,  and  death  was  produced  only 
when  the  dose  was  increased  to  from  4  to  6  cubic  centimetres.  Injection 
of  cultures  of  the  streptococcus  pyogenes  into  the  peritoneal  cavity  was 
even  better  tolerated,  and  usually  had  to  be  repeated  several  times  before 
the  animal  died  of  septic  peritonitis.  A  needle  dipped  into  a  culture  of 
pus-microbes  he  could  insert  into  joints  without  causing  suppuration;  but 
the  injection  of  from  0.3  to  0.5  cubic  centimetre  of  a  mixture  of  pus- 
microbes  suspended  in  distilled  water,  into  the  hip-joint  of  rabbits,  was 
followed  by  suppurative  arthritis,  rupture  of  the  capsule,  and  diffuse  par- 
aarticular phlegmonous  inflammation  and  suppuration,  and  often  death  of 
the  animal.  Injection  of  1  or  3  drops  of  a  liquefied-gelatin  culture  of  the 
staphylococcus  pyogenes  aureus,  or  albus,  into  a  vein  of  a  rabbit  did  not 
produce  any  serious  disturbance;  but,  if  the  dose  was  increased  to  from 
0.5  to  1  cubic  centimetre,  it,  as  a  rule,  caused  a  fatal  disease.  In  such 
cases  multiple  suppurating  foci  were  found  in  the  kidney,  liver,  spleen, 
and  lungs,  with  pleiTritis  and  peritoneal  effusion,  pericarditis,  and  myo- 
carditis; also  serous  and  purulent  effusions  into  joints  and  muscular 
abscesses. 

The  effect  of  inoculation  with  pus-microbes  in  man  is  the  same  as  in 
animals.  Garre  made  a  superficial  abrasion  on  one  of  his  fingers,  and  ap- 
plied a  piire  culture  of  the  staphylococcus  pyogenes  aureus;  the  only  symp- 
tom observed  was  a  slight  redness  eighteen  to  twenty-four  hours  after  the 
inoculation.  He  then  made  three  small  incisions,  and  inoculated  himself 
with  a  larger  quantity  of  the  culture,  which  was  followed  by  superficial 
suppuration. 

Fehleisen  repeated  precisely  similar  experiments  upon  himself  with 
cultures  of  different  kinds  of  pus-microbes,  and,  if  he  succeeded  in  causing 
suppuration,  this  was  always  very  slight.  He  also  found  that  minute  doses, 
administered  subcutaneously,  were  harmless;  while  larger  doses,  sus- 
pended in  water,  almost  without  exception  caused  abscesses,  and,  in  ani- 
mals, very  large  doses  produced  death  from  sepsis  before  suppuration  could 
take  place.  Bockhardt  introduced  a  trace  of  a  mixed  culture  of  staphylo- 
coccus aureus  and  albus  into  the  cutis  of  his  left  forefinger;  after  forty- 
eight  hours  a  small  abscess  had  formed,  which  was  opened,  and  in  the  pus 
the  same  microbes  were  demonstrated.  Bumm  injected  a  pure  culture  of 
the  yellow  staphylococcus  into  the  subcutaneous  tissue  of  his  own  arm, 
and  into  the  arms  of  two  other  persons.  In  each  instance  an  abscess  de- 
veloped, which  varied  from  the  size  of  a  pigeon's  egg  to  that  of  a  man's 
fist,  according  to  the  time  which  elapsed  before  they  were  opened.  In  the 
pus  of  these  abscesses  the  same  pus-microbe  which  had  been  injected  was 
found.      The   above    observations   are    conclusive    in   showing   that   pus- 


DIEECT    CAUSES    OF    SUPPUEATION.  327 

microbes  can  be  cultivated  from  the  pus  of  every  acute  abscess,  and  that, 
in  man  and  animals,  the  injection  of  a  sufficient  quantity  of  a  pure  culture 
into  the  tissues  is  followed  by  suppuration;  and  thus  far  positive  proof 
has  been  furnished  of  the  direct  etiological  relationship  which  exists  be- 
tween pus-microbes  and  suppuration.  Einne  published  an  account  of  his 
experiments,  and  his  results  are  somewhat  in  conflict  with  the  authorities 
quoted  above.  He  frequently  failed  to  produce  su]3purative  inflammation, 
even  when  he  injected  a  large  quantity  of  a  pure  culture,  and  by  repeating 
the  injection  from  time  to  time.  He  is  of  the  opinion  that,  when  the 
absorptive  capacity  of  the  tissues  is  not  diminished,  the  pus-microbes  are 
removed  too  rapidly  to  produce  their  pathogenic  effect.  The  effect  of 
inoculation  with  pus-microbes  will,  of  course,  always  vary,  according  to  the 
quantity  of  the  microbes  and  the  local  and  general  susceptibility  of  the 
animal  experimented  on.  Watson  Cheyne  has  shown  most  conclusively 
that  the  number  of  bacteria  introduced  greatly  modifies  not  only  the  in- 
tensity of  the  symptoms,  but  also  the  character  of  the  disease.  His  experi- 
ments were  made  with  cultivations  of  Hauser's  proteus  vulgaris.  He  esti- 
mated that  ^/lo  cubic  centimetre  of  an  undiluted  culture  of  this  microbe 
contains  225,000,000  bacteria,  and  when  this  quantity  was  injected  into 
the  muscular  tissue  of  a  rabbit  it  produced  speedy  death.  A  quantity  of 
the  same  culture  corresponding  with  V40  cubic  centimetre,  administered 
in  the  same  manner,  caused  an  extensive  abscess  at  the  point  of  injection, 
and  death  of  the  animal  in  six  or  eight  weeks.  Doses  of  less  than  V500 
cubic  centimetre  produced  no  effect, — in  fact,  doses  of  less  than  V12  "to 
^/i2o  cubic  centimetre,  or,  in  other  words,  fewer  than  about  18,000,000  bac- 
teria, seldom  caused  any  positive  result.  The  same  author  found  that  in 
the  case  of  the  staphylococcus  pyogenes  aureus  it  was  necessary  to  inject 
something  like  1,000,000,000  cocci  into  the  muscles  of  rabbits,  in  order 
to  cause  a  rapidly-fatal  result,  while  250,000,000  produced  a  small  abscess. 
In  the  case  of  the  tetanus  bacillus,  death  did  not  occur  in  rabbits  when 
fewer  than  1000  bacilli  were  introduced.  He  believes,  as  does  Einne,  that 
the  action  of  the  preformed  toxins  on  the  tissues  modifies  the  result.  It 
is,  therefore,  probable  that,  in  the  experiments  in  which  injection  of  pus- 
microbes  did  not  produce  suppuration,  an  insufficient  number  of  active 
microbes  were  used,  and  that  where  indifferent  substances  and  chemical 
irritants  caused  suppuration  the  implanted  or  injected  material  was  con- 
taminated, or  that  infection  at  the  point  of  injection  occurred  through  the 
wound,  or  subsequently  through  the  circulation.  The  latter  method  of 
infection  should  always  be  borne  in  mind  in  cases  where  the  presence  of 
an  aseptic  substance  in  the  tissues  has  apparently  been  the  cause  of  sup- 
puration. The  tissues  altered  by  the  action  of  chemical  irritants  consti- 
tute a  foreign  substance,  which  may  determine  localization  of  microbes 


238  PEIXCIPLES    OF    SUEGEEY. 

floating  in  the  circulation,  while,  at  the  same  time,  the  chemical  altera- 
tions which  they  have  caused  in  the  tissues  have  prepared  a  favorable  soil 
for  their  reproduction.  Of  late  a  number  of  pathologists  have  gone  one 
step  further,  and  maintain  that  pus-microbes  are  not  the  direct  cause  of 
suppuration,  but  that  their  presence  is  essential  for  the  production  of 
toxins,  to  which  they  attribute  pyogenic  properties.  If  certain  pyogenic, 
aseptic,  chemical  substances  can  convert  living  cellular  elements  into  pus- 
corpuscles,  as  has  been  asserted  upon  good  authority,  we  should  naturally 
expect  that  chemical  substances  produced  by  pus-microbes  in  inflamed 
tissue  might  possess  the  same  pathogenic  property,  and  we  will  briefly  con- 
sider what  is  known  in  reference  to 

Toxins  of  Pus-microbes  as  a  Cause  of  Suppuration. — Grawitz  and 
de  Bary,  after  detailing  the  results  of  their  experiments  with  injections 
of  chemical  irritants  in  their  investigations  on  pus-formation,  give  an  ac- 
count of  their  experiments  with  the  toxins  of  pus-microbes.  They  main- 
tain that  these  toxins,  like  chemical  irritants,  prepare  the  tissues  for  the 
growth  and  reproduction  of  pus-microbes.  The  action  of  these  substances 
can  be  studied  by  injecting  sterilized  cultures  of  pus-microbes,  in  which 
the  only  active  agents  could  be  the  preformed  toxins.  These  observers 
injected  4  cubic  centimetres  of  a  sterilized  culture  of  the  staphylococcus 
]3yogenes  aureus  under  the  skin  of  a  dog,  with  the  effect  of  causing  sup- 
puration. The  pus  was  examined  for  microbes,  but  none  were  found. 
They  assert  that  the  presence  of  oxygen  is  of  the  greatest  importance  in 
the  production  of  toxins.  Grawitz  experimented  also  with  a  pure  prepara- 
tion of  cadaverin,  prepared  by  Brieger  from  bacteria.  Cadaverin  is  a 
colorless  fluid,  the  chemical  formula  of  which  is  identical  with  penta- 
methylendiamin;  a  2  ^/2-per-cent.  solution  of  this  substance  destroyed  the 
staphylococcus  pyogenes  aureus  in  an  hour,  and  a  small  quantity  added  to 
a  culture  of  pus-microbes  arrested  further  growth.  A  solution  absolutely 
free  from  microbes,  injected  under  the  skin  of  animals,  according  to 
strength  and  quantity  used,  produced  cauterization  or  inflammation,  ter- 
minating in  suppuration  or  inflammatory  cedema,  followed  by  resolution 
and  absorption.  The  pus  produced  by  cadaverin  contained  no  bacteria  as 
long  as  the  skin  remained  intact.  The  injection  of  a  mixture  of  a  solution 
of  cadaverin  and  pus-microbes  was  always  followed  by  a  progressive  phleg- 
monous inflammation.  Scheuerlen  was  the  first  to  study  the  local  action 
of  toxins  on  the  tissues.  He  introduced  into  the  subcutaneous  connective 
tissue  of  rabbits  aseptic  glass  capsules  containing  sterilized  infusion  of 
meat.  The  wounds  healed  by  primary  union.  As  soon  as  the  capsules  had 
become  encysted,  he  broke  off  both  ends  of  the  capsule,  so  as  to  saturate 
the  tissues  in  its  immediate  vicinity  with  the  fluid  it  contained.  Three 
to  six  weeks  after  implantation  of  the  capsule  an  incision  was  made  down 


DIEECT    CAUSES    OF    SUPPURATION.  329 

to  it,  and  the  jDarts  submitted  to  a  thorough  examination.  The  ends  of 
the  capsule  were  always  found  to  contain  a  few  drops  of  thin,  yellow  pus, 
which,  under  the  microscope,  showed  all  the  characteristic  appearances  of 
that  fluid.  No  inflammation  of  the  surrounding  tissues.  Cultivation  ex- 
jjeriments  with  the  pus  yielded  negative  results.  It  is  evident  that  sup- 
puration in  these  instances  was  caused  by  the  action  of  the  preformed 
toxins  on  the  leucocytes  and  embryonal  cells,  and  that  its  extension  did 
not  occur  because  the  cause  did  not  multiply  in  the  tissues.  In  about 
twenty  experiments  the  pus  was  found  only  inside  of  the  capsule.  Weigert 
has  repeatedly  shown  that  the  difl:erence  between  a  purulent  and  fibrinou-S 
exudation  can  be  readily  demonstrated,  as  the  former  does  not  coagulate, 
although  white  corpuscles  and  plasma  may  be  present. 

Klemperer  believes  that  this  difl:erence  is  due  to  previous  destruction 
of  fibrinogen  in  the  pus  by  the  pus-microbes.  The  putrid-meat  infusion 
used  by  Scheuerlen  caused  limited  su^Dpuration,  and  on  that  account  it 
must  also  have  possessed  the  property  to  prevent  coagulation.  To  prove 
this  he  made  the  following  experiment:  The  abdomen  of  a  rabbit  was 
opened  while  the  animal  was  under  the  influence  of  chloroform,  and  blood 
was  drawn  directly  from  the  aorta  into  a  glass  tube  containing  putrid  ex- 
tract of  meat.  As  the  fluids  gradually  became  mixed  the  blood  assumed  a 
brownish-red  color;  coagulation  did  not  occur  for  hours  and  days,  while 
in  the  control  experiments,  with  solution  of  salt,  the  blood  coagulated 
firmly  after  the  lapse  of  a  few  minutes.  He  next  made  thirty  cultures  of 
the  staphylococcus  pyogenes  aureus  upon  agar-agar  gelatin,  and  the  same 
number  of  cultures  of  the  albus,  and  after  completion  of  their  growth, 
fourteen  days  later,  he  sterilized  them  with  boiling  water,  and,  after  shak- 
ing the  fluid,  removed  the  cultures  and  boiled  them  for  a  few  minutes,  and 
finally  filtered  them;  he  thus  obtained  about  150  cubic  centimetres  of  a 
light-yellow  fluid.  This  was  reduced  to  8  cubic  centimetres  by  boiling; 
before  using,  the  fluid  was  again  flltered.  The  flltrate  was  put  in  capsules, 
and  after  sealing  their  ends  hermetically  they  were  inserted  into  the  sub- 
cutaneous connective  tissue  of  animals  with  the  same  care  as  in  the  preced- 
ing experiments.  The  suppuration  which  followed  the  breaking  of  the 
glass  capsule  in  these  cases  was  again  found  to  be  limited  to  the  space 
within  the  capsule,  being  caused  by  action  of  the  preformed  toxins  on  leu- 
cocytes and  embryonal  cells,  which  found  their  way  into  the  interior  of 
the  glass  capsule. 

The  cadaverin  and  putrescin,  two  ptomaines  prepared  by  Brieger, 
were  next  experimented  with  in  the  same  manner.  In  preventing  coagula- 
tion the  results  Avere  even  more  striking  than  with  the  former  substances. 
These  experiments  leave  no  doubt  that  toxins  derived  from  pyogenic  bac- 
teria produce  a  chemical  action  on  leucocytes  and  embryonal  cells  by 


230  PEINCIPLES    OF    SUEGEEY. 

which  they  are  converted  into  pus-corpuscles.  The  suppuration  thus  pro- 
duced, however,  never  extends  beyond  the  tissues  which  are  brought  in 
contact  with  them,  and,  therefore,  always  remain  circumscribed.  In  this 
respect  the  results  of  the  experiments  just  cited  do  not  correspond  with  sup- 
puration as  ive  observe  it  in  practice,  as  here  from  the  same  causes,  mid  ap- 
parently often  under  the  same  conditions,  the  process  presents  the  greatest 
possible  variations  in  reference  to  Us  intensity  and  extent.  In  one  case  the 
suppuration  remains  circumscribed,  resulting  in  a  furuncle;  in  others  the 
regional  infection  is  more  extensive,  and  a  diffuse,  phlegm€nous  inflammation 
is  the  result;  while  in  the  third  class  the  local  infection  leads  to  general  sys- 
temic invasion,  and  the  patient  dies  of  sepsis  or  pycemia.  The  clinical  form 
of  suppuration  is  noted  for  the  progressive  character  of  the  infection, 
which  is  due  to  the  reproduction  of  pus-microbes  in  the  tissues  and  the 
production  of  toxins  proportionate  in  amount  to  the  number  of  microbes 
present,  and,  perhaps,  also  modified,  to  a  certain  extent,  by  the  character 
of  the  soil.  Practically,  the  matter  remains  the  same  as  before  it  was 
known  that  the  toxins  produced  in  the  tissues  by  the  pyogenic  microor- 
ganisms could  cause  suppuration,  as  pus-microbes  must  be  introduced 
into  the  organism,  where  they  must  also  find  an  appropriate  soil  for  their 
reproduction,  before  toxins  can  be  produced  in  sufficient  quantity  to  ac- 
count for  the  occurrence  of  the  clinical  forms  of  suppuration.  To  the 
practical  surgeon  it  is  immaterial  to  know  whether  the  transformation 
of  leucocytes  and  embryonal  cells  into  pus-corpuscles  is  brought  about  by 
the  direct  action  of  pus-microbes  or  by  the  toxins  which  they  produce  in 
the  tissues. 

Bescription  and  Specific  Action  of  the  Different  Pus-microbes. — The 
microbes  which,  when  present  in  sujB&cient  number  in  the  tissues,  excite 
suppurative  inflammation  are  called  pyogenic  or  pus-  microbes.  Their 
effect  on  the  cellular  elements  of  the  inflammatory  product  is  a  specific 
one,  converting  them  into  pus-corpuscles.  Only  such  microbes  will  be 
described  here  which  have  been  cultivated  from  pus,  and  the  specific  action 
of  which  has  been  demonstrated  experimentally. 

1.  Staphylococcus  Pyogenes  Aureus.  • — •  The  yellow  staphylococcus  is 
the  microbe  most  frequently  present  in  acute  abscesses.  Under  the  micro- 
scope it  cannot  be  distinguished  from  the  staphylococcus  pyogenes  albus. 

It  is  easily  cultivated  upon  gelatin,  agar-agar,  coagulated  blood-serum, 
and  potato.  The  culture  liquefies  gelatin.  It  grows  best  at  a  temperature 
approaching  that  of  the  blood,  but  can  be  cultivated  at  30°  C.  It  pep- 
tonizes albumen  and  coagulates  milk.  The  culture  grows  in  the  track  of 
the  needle  and  upon  the  surface  of  the  nutrient  medium.  The  gold-yellow 
color  of  the  culture  appears  only  if  the  colony  is  exposed  to  atmospheric 
air.     Cultures  upon  gelatin  or  agar-agar  retain  their  virulence  for  a  year 


DIEEOT   CAUSES    OF    SUPPUEATION.  331 

or  more.     This   coccus   is  met  with   frequently  in   acute   circumscribed 
abscesses,  osteomyelitis,  pyaemia,  and  ulcerative  endocarditis. 

2.  Staphylococcus  Pyogenes  Albus. — This  pus-microbe  can  be  distin- 
guished from  the  yellow  coccus  only  by  the  color  of  the  culture,  which  is 
white.  Both  Passet  and  Klebs  have  observed  in  the  white  culture  of  this 
coccus  small  yellow  dots,  which,  when  isolated,  lost  their  color.  These 
authors,  therefore,  consider  the  yellow  and  white  staphylococci  as  varieties 
of  the  same  kind  of  pus-microbes.  As  other  experimenters  have  not  been 
able  to  verify  these  observations,  we  must  take  it  for  granted  that  the 
staphylococcus  pyogenes  albus  differs  from  the  aureus  in  that  it  possesses 
no  power  to  produce  the  same  yellow  color  which  characterizes  the  culture 
of  the  latter.  Its  pathogenic  properties,  both  in  man  and  animals,  are 
somewhat  less  than  those  of  the  aureus.  Passet  claims  that  the  white 
coccus  is  more  frequently  found  in  the  suppurative  lesions  in  man  than 
the  yellow,  while  Eosenbach  makes  a  contrary  assertion.  The  latter 
author  seldom  found  it  alone  in  pus,  but  more  frequently  associated  with 
the  aureus.     The  cultures  of  both  the  yellow  and  white  staphylococcus 

I 

'■^^^^ 

•#  .IS? 


Fig.  86.— Microscopical  Pictures  of  Stapliylococcus.    1,  culture  twenty-four 
hours;    2,  culture  two  months.     (Bosenbach.) 

upon  gelatin  present  an  irregular  surface,  and  the  margins  are  dotted  with 
minute  globular  projections.  Both  of  these  microbes  liquefy  gelatin,  but 
agar-agar  and  coagulated  blood-serum  are  not  similarly  affected. 

3.  Staphylococcus  Pyogenes  Citreus. — Found  by  Passet  in  about  10 
per  cent,  of  acute  abscesses  examined.  Like  the  aureus  and  albus,  it 
liquefies  gelatin.  Cocci  singly,  or  in  pairs,  or  zoogloea.  If  cultivated  on 
nutrient  gelatin,  or  agar-agar,  a  sulphur  or  lemon-yellow  growth  develops 
after  twenty-four  hours,  which  at  that  time  resembles  the  aureus,  but 
later  does  not  change  into  a  gold-yellow  color.  Like  the  aureus,  pigmenta- 
tion only  takes  place  if  the  culture  is  exposed  to  air.  According  to  Passet, 
its  virulence  is  somewhat  less  than  that  of  the  aureus  and  albus.  This 
statement  has  been  confirmed  by  Cheyne.  When  a  culture  of  this  pus- 
microbe  is  injected  under  the  skin  of  mice,  guinea-pigs,  or  rabbits,  an 
abscess  forms,  from  the  pus  of  which  a  culture  of  the  same  lemon  color 
can  be  obtained. 

4.  Staphylococcus  Cereus  Albus. — This  microbe  was  first  discovered 
by  Passet  in  the  pus  of  a  periosteal  abscess  of  a  finger,  as  well  as  in  an 
abscess  of  the  heel.    A  culture  upon  gelatin  is  distinguished  from  that  of 


233  >  PEINCIPLES    OF    SUEGERY. 

other  pus-microbes  upon  the  sarae  nutrient  medium  by  its  forming  a 
white^  slightly-shining  layer,  like  drops  of  white  wax,  with  a  somewhat 
thickened,  irregular  edge.  The  needle-stab  develops  into  a  grayish- white, 
granular  thread.  In  plate  cultures,  on  the  first  day,  white  points  are  ob- 
served, which  spread  themselves  out  on  the  surface  to  spots  one-half  a 
millimetre  in  diameter;  when  cultivated  on  blood-serum,  a  grayish- white, 
slightly-shining  streak  develops;  and  on  potato  the  cocci  form  a  layer 
which  is  similarly  colored.     This  microbe  is  not  pathogenic  in  rabbits. 

5.  Staphylococcus  Cereus  Flavus. — Passet  cultivated  this  microbe  from 
the  pus  of  a  case  of  chronic  periostitis  of  the  tibia.  If  cultivated  on 
gelatin,  the  growth,  which  is  at  first  white,  becomes  of  a  citron-yellow 
color,  resembling  somewhat  yellow  wax,  considerably  darker  than  the 
culture  of  staphylococcus  pyogenes  citreus.  Both  varieties  of  staphylo- 
coccus cereus  are  very  rarely  met  with  in  abscesses,  and  inoculation  ex- 
periments with  them  have  usually  proved  harmless.  Baumgarten  thinks 
it  possible  that  in  cases  where  they  were  found  in  abscesses  they  were  not 
the  cause  of  suppuration,  but  occurred  as  an  accidental  invasion  after  the 
pyogenic  microbes  had  disappeared. 

6.  Staphylococcus  Flavescens. — This  microbe  was  found  in  an  abscess 
by  Babes,  and  occupies  an  intermediate  position  between  the  staphylo- 
coccus pyogenes  aureus  and  albus.  On  gelatin,  the  growth  forms  a  color- 
less layer  and  causes  liquefaction.  It  is  fatal  to  mice,  sometimes  causing 
abscesses,  and,  in  large  doses,  septicsemia. 

Welch  described,  a  few  years  ago,  a  white  staphylococcus  which  he 
found  constantly  upon  and  in  the  skin,  which  he  called  staphylococcus 
epidermidis  albus.  To  this  microbe  he  attributes  the  frequent  occurrence 
of  stitch-abscesses  after  operations  during  which  the  ordinary  strict  anti- 
septic precautions  are  carried  out. 

7.  Micrococcus  Pyogenes  Tenuis. — Eosenbach  found  this  microorgan- 
ism in  a  large  abscess  which  had  given  rise  to  no  general  symptoms.  It 
is  of  rare  occurrence.  On  agar-agar  it  forms  an  exceedingly  delicate, 
almost  invisible,  white  film.  The  individual  cocci  are  irregular  in  shape 
and  larger  than  the  staphylococci. 

In  all  cases  in  which  this  microbe  is  the  sole  bacterial  cause  of  sup- 
puration, the  process  appears  to  have  been  unattended  by  any  very  severe 
inflammatory  symptoms  and  little  or  no  general  febrile  disturbances.  This 
microbe  was  not  found  by  any  one  else  but  Eosenbach  until  February, 
1888,  when  Easkina  isolated  it  from  the  pus  and  organs  in  a  case  of  scar- 
latina complicated  Avith  pyaemia,  which  resulted  fatally  on  the  eighteenth 
day  after  the  beginning  of  the  primary  disease.  At  the  necropsy  multiple 
miliary  abscesses  were  found  in  the  kidneys,  at  the  junction  of  the  cortex 
with  the  medullary  portion.    From  the  pus  of  these  abscesses  a  pure  cult- 


DIRECT    CAUSES    OF    SUPPUEATION. 


233 


Fig.  87. — Common  Forms  of  Pus-microbes.  1.  Staphylococcus  pyogenes  aureus 
from  a  pyelonephritis  in  a  man.  (Gram's  method.)  2.  Bacillus  pyocyaneus  from  a 
"green-pus"  abscess.  (Loeffler's  methylene-blue.)  3.  Streptococcus  pyogenes  from 
knee-joint  of  man  dying  of  septicaemia.  (Loeffler's  methylene-blue.)  4.  Bacillus  coli 
commune  and  micrococcus  tetragenus.  Twenty-four-hour  growth  on  glycerin-agar  from 
peritoneum  of  a  woman  dying  of  peritonitis.     (Loeffler's  methylene-blue.) 


234  PRINCIPLES    OF    SUEGERY. 

lire  of  the  micrococcus  was  obtained.  Inoculation  experiments  made  on 
rabbits  gave  only  negative  results,  even  though  the  coccus  was  present 
in  the  blood  twenty-four  hours  after  inoculation;  hence  it  is  problematical 
as  to  its  being  a  pyogenic  microbe.  Like  the  staphylococcus  cereus,  it 
probably  belongs  to  the  so-called  metabiotic  microbes  of  G-arre,  occurring 
secondarily  after  suppuration  has  been  established  by  genuine  pyogenic 
microbes. 

8.  Streptococcus  Pyogenes. — -Cocci,  somewhat  larger  than  staphylo- 
cocci, always  divide  transversely;  so  that  they  arrange  themselves  in  the 
form  of  chains,  which  are  usually  more  or  less  curved. 

The  cocci  also  appear  singly  or  as  diplococci.  Cultures  grow  very 
slowly  on  ordinary  nutrient  media  at  summer  temperature,  but  with  great 
rapidity  at  the  temperature  of  the  body.  Cultivated  in  a  streak  on  the 
surface  of  gelatin  on  a  glass  plate,  this  microbe  forms  at  first  whitish, 
somewhat  transparent,  rounded  spots,  of  the  size  of  small  grains  of  sand. 
On  agar-agar  it  grows  most  luxuriantly  at  a  temperature  of  35°  to  37°  C. 


X. 

Fig.  88.  Fig.  89. 

Fig.  88. — Micrococcus  Pyogenes  Tenuis.     Cultivated  from  pus  in  a 

Case  of  Empyema.     (Rosenbach.) 
Fig.    89. — Streptococcus   Pyogenes.      (Rosenbach.) 

Even  if  the  inoculation  is  made  with  the  point  of  a  needle  in  a  continuous 
line,  the  culture  appears  in  isolated,  small  points.  In  its  further  growth 
the  culture  is  elevated  in  the  centre,  and  presents  a  pale-brownish  color, 
while  the  periphery  is  flattened,  except  at  the  extreme  margin,  which  is 
again  raised,  and  often  with  a  spotted  appearance.  Still  later  the  periph- 
ery develops  successive  layers  or  terraces,  which  were  pointed  out  by 
Eosenbach  as  characteristic  macroscopical  features  of  the  cultures  of  this 
microbe  upon  solid  nutrient  media.  The  growth  is  so  slow  that  in  two 
or  three  weeks  the  maximum  width  of  the  culture-streak  is  about  2  or  3 
millimetres.  In  a  vacuum  the  streptococcus  effects  peptonization  of  albu- 
men and  beef.  Subcutaneous  inoculation  in  mice  yields  negative  results 
in  about  80  per  cent.;  sometimes  a  slight  suppuration  follows  at  the  seat 
of  puncture;  at  times  the  animal  dies  without  showing  any  particular 
pathological  lesions,  and  no  microorganisms  can  be  found  in  any  of  the 
internal  organs.  In  the  subcutaneous  tissue  of  rabbits  in  small  quantities 
they  cause  hyperemia,  redness,   and  slight  swelling,  which  disappear  in 


DIEECT    CAUSES    OF    SUPPUEATION.  235 

the  course  of  two  or  three  days;  when  larger  quantities  are  used,  some 
authors  claim  that  they  produce  small  circumscribed  abscesses.  In  healthy 
rabbits  intravenous  injection  of  even  a  pure  culture  of  the  streptococcus 
causes  no  serious  symptoms.  If  the  animals  are  debilitated  previously 
by  injections  of  toxic  substances,  death  is  caused  by  rapid  reproduction  of 
the  microbe  in  the  tissues.  If  a  pure  culture  is  injected  into  a  serous 
cavity,  it  causes,  first,  inflammation,  and,  later,  effusion,  which  is  again 
absorbed.  In  the  pus  from  the  human  subject  the  streptococcus  is  found 
in  about  40  to  60  per  cent,  of  the  specimens  examined.  This  pus-microbe 
invades  the  tissues  far  in  advance  of  suppuration.  It  is  found  most  fre- 
quently in  inflammations  following  the  lymphatic  channels.  It  is  also 
found  in  grave  affections,  in  progressive  gangrene.  In  several  cases  of 
pyaemia  cultures  of  the  pus  yielded  a  growth  composed  exclusively  of  the 
streptococcus. 

9.  Bacillus  Pyogenes  Foetidus. — Passet  found  this  microorganism  in 
the  pus  of  a  perirectal  abscess.  This  bacillus  possesses  slow  motion,  its 
ends  are  rounded,  and  in  cultures  appears  usually  in  pairs. 


Fig.  90.  Fig.  91. 

Fig.  90.— BaclUus  Pyogenes  Foetidus.     X  790.     (Fluegge.) 
Fig.  91.— BaciUus  Pyocyaneus.    X  700.    (Fluegge.) 

In  stained  specimens  each  bacillus  shows  in  its  interior  one  or  two 
spores.  This  bacillus  grows  on  gelatin,  forming  a  delicate  white  or  gray- 
ish layer  on  the  surface,  but  causes  no  liquefaction.  When  cultivated  on 
agar-agar  and  potato  it  has  the  appearance  of  a  light-brown,  glistening 
layer,  which  emits  a  very  offensive  odor.  In  mice  traces  of  the  culture 
do  no  harm;  the  injection  of  several  drops  causes  septicaemia.  Injection 
of  about  10  minims  of  the  culture  into  guinea-pigs  causes  an  abscess,  in 
which  the  bacilli  alone  are  found  as  pyogenic  cause;  direct  intravenous  in- 
jection causes  sepsis. 

10.  Bacillus  Pyocyaneus. — It  has  been  known  for  a  long  time  that  the 
greenish-blue  color  of  the  pus,  frequently  found  in  the  pus  of  suppurating 
wounds,  is  due  to  the  presence  of  a  color-producing  microbe.  The  investi- 
gations of  G-essard  and  Charrin,  Ernst,  Fordos,  and  Ledderhose  have  shown 
that  this  chromogenic  microbe  is  the  bacillus  pyocyaneus.  Freudenreich 
found,  as  a  result  of  his  numerous  experiments,  that  the  bacillus  pyo- 
cyaneus causes  a  change  in  bouillon  which  renders  it  unfit  for  the  growth 


236  PEINCIPLES    OF    SUKGEEY. 

of  other  species.  In  the  pus  and  on  solid  culture-media  the  bacilli  appear 
in  pairs,  small  groups,  or,  what  is  more  common,  large  masses,  or  zoogioea. 
This  bacillus  grows  upon  gelatin,  which  liquefies  and  is  stained  a 
greenish  blue.  It  also  grows  vigorously  on  agar-agar  and  potato,'  both  of 
these  substances  being  stained  a  greenish  hue.  In  milk  it  causes  caseation, 
with  subsequent  peptonization  of  the  casein  and  simultaneous  appearance 
of  ammonia,  while  the  coloring  material  appears  on  the  surface  in  the 
form  of  greenish-yellow  spots.  Fordos  and  Gessard  isolated  the  coloring 
material  which  this  bacillus  produces,  and  called  it  pyocyanin.     It  is 


Fig.  92.— Bacillus  Pyocyaueus.     X  700. 

soluble  in  chloroform,  and  from  a  pure  solution  crystallizes  in  long,  blue 
needles.  Gessard  found  that  a  temperature  of  57°  C,  maintained  for  five 
minutes,  destroyed  the  chromogeuic  power  of  the  bacillus  pyocyaueus 
without  destroying,  the  vitality  of  the  bacillus,  which  was  propagated 
through  successive  cultures  without  regaining  this  power. 

Fliigge  asserts  that  this  bacillus  is  devoid  of  pyogenic  properties,  and 
appears  only  as  a  harmless  settler  upon  wounds.  Ledderhose,  by  culti- 
vating this  bacillus  upon  a  large  scale,  obtained  a  considerable  quantity 
of  pyocyanin,   and  by  chemical   analysis   determined  its   formula   to   be 


m  <^  ^',il 


Fig.  93.— Gonococcus.     (After  Bumm.) 

C14II14,  N2C.  In  doses  of  1  gramme,  as  muriate  of  pyocyanin,  injected 
into  the  circulation  of  different  animals,  he  observed  no  toxic  symptoms. 
When  a  pure  culture  of  the  bacilli  was  injected,  he  produced  suppurative 
inflammation,  and  attributes  this  result  not  to  the  presence  of  pyocyanin, 
but  to  other  as  yet  unknown  phlogistic  and  pyogenic  substances  elaborated 
by  the  bacillus  in  the  tissues. 

The  practical  surgeon  looks  upon  the  bacillus  pyocyaueus  as  a  com- 
paratively benign  pus-microbe,  but  cases  are  not  wanting  in  which  this 
organism  was  found  as  the  only  microbic  cause  in  diffuse  septic  processes. 


DIKECT    CAUSES    OF    SUPPUEATION. 


237 


This  bacillus  is  normally  found  in  the  skin  as  a  saprojohyte.  It  has  a 
predilection  for  certain  localities  of  the  body,  as  the  axilla,  ingaiinal 
region,  anus,  etc.  The  odor  of  pus  produced  by  the  bacillus  is  SAveetish, 
musty,  and  at  times  slightly  or  very  offensive. 

11.  Micrococcus  Gronorrhoese.  —  The  micrococcus  of  gonorrhoea,  also 
called  gonococcus,  was  discovered  by  Keisser  in  1879,  who  also  demon- 
strated the  etiological  relationship  between  this  microbe  and  gonorrhoea. 
Bumm  first  succeeded  in  cultivating  it  upon  artificial  nutrient  media  and 
made  a  special  study  of  its  morphology  and  pathogenesis.  The  gonococcus 
always  occurs  in  pairs,  and  is,  therefore,  a  diplococcus. 

The  cocci  appear  as  hemispherical  bodies  with  their  flattened  surfaces 
in  apposition,  which  imparts  to  the  microbe  the  characteristic  biscuit- 


Pig.  94 — (joiioiihceal  Pus 

shaped  appearance.  The  gonococci  are  found  in  clusters  or  clumps  upon 
or — what  is  more  common,  as  Bumm  asserts — within  the  pus-corpuscles 
of  gonorrhoeal  pus.  The  microbes  within  the  corpuscle  may  become  so 
numerous  as  to  fill  the  entire  space  with  the  exception  of  the  nucleus. 

The  mucous  membrane  of  the  urethra  and  the  conjunctiva  are  the 
localities  most  predisposed  to  the  pathogenic  action  of  the  gonococcus. 
The  gonorrhoeal  inflammation,  which  is  at  first  superficial,  penetrates 
more  deeply  into  the  mucous  membrane  with  the  advancing  gonococci, 
which  invade  the  epithelial  cells. 

Bumm,  Bockhardt,  and  others  have  reported  cases  of  mixed  gonor- 
rhoeal infection  in  which  pus-microbes,  acting  upon  tissues  altered  by  the 
gonorrhoeal  infiammation,  gave  rise  to  abscesses  in  the  glands  of  Bartholin, 


238  PEINCIPLES    OF    SUKGEEY. 

to  cystitis,  pelvic  cellulitis,  and  suppurative  synovitis.  Suppuration  iu 
joints,  peritoneum,  and  connective  tissue  the  seat  of  gonorrhoeal  infection 
is  prone  to  occur  in  the  course  of  secondary  infection  with  more  potent 
pyogenic  microbes. 

12.  Bacillus  Coll  Comnmnis. — This  microbe  was  first  discovered  by 
Emmerich,  in  1885,  in  the  blood,  various  organs,  and  the  dejections  of 
cholera  patients  at  Naples.  A  year  later  Escherich  showed  that  it  is 
constantly  present  in  the  alvine  discharges  of  healthy  persons.     It  is  a 


Fig.  95. — GonorrhcEal  Conjunctivitis,  Second  Day  of  Sickness.  Section  through  the 
mucous  membrane  of  upper  eyelid;  invasion  of  the  epithelial  layer  by  gonococci.  (After 
Bumm.) 

short  and  thick  bacillus  (Fig.  96)  with  rounded  ends;  the  prevailing  form 
in  culture  is  a  short  oval.  The  bacilli  are  frequently  united  in  pairs.  It 
stains  readily  with  aniline  dyes,  but  is  decolorized  promptly  when  treated 
with  a  solution  of  iodine.  It  is  an  aerobic  and  facultative  anaerobic,  non- 
liquefying  bacillus.  It  is  non-motile,  and  does  not  multiply  by  spores. 
It  grows  readily  in  various  culture-media.  In  gelatin  stick  cultures  the 
growth  on  the  surface  is  rather  dry  and  thin;  in  old  cultures  it  covers  the 
entire  surface. 


% 


Fig.  96. — Bacillus  Coli  Communis. 

The  bacillus  coli  communis  is  the  most  frequent  cause  of  intestinal 
sepsis.  It  is  constantly  present  in  the  appendix  vermiformis,  and  is  the 
most  fruitful  source  of  the  different  forms  of  acute  and  chronic  inflam- 
mation of  this  organ.  As  this  bacillus  gains  entrance  under  favorable  con- 
ditions into  the  different  ducts  and  glands  in  communication  with  the  in- 
testinal canal,  it  is  often  the  direct  cause  of  suppurative  inflammation  in 
organs  in  direct  connection  or  close  contact  with  the  intestinal  tract, — 
notably  the  liver  and  biliary  passages.     The  pyogenic  properties  of  this 


DIEECT   CAUSES    OF    SUPPUEATION.  239 

microbe  have  been  quite  recently  studied  with  great  care^,  and  pure  cult- 
ures have  been  obtained  from  abscesses  remote  from  the  intestinal  tract, 
which  proves  that  it  retains  its  specific  pathogenic  properties  after  its 
entrance  into  the  tissues. 

The  colon  bacillus  probably  finds  its  way  more  frequently  into  the 
general  circulation  than  any  other  pathogenic  microbes.  It  is  fortunate 
that  the  organism  makes  provision  for  such  an  event  by  the  creation  of 
resisting  agencies  which  often  suffice  in  the  prevention  of  general  infec- 
tion. Adami  has  shown  conclusively  the  bactericidal  action  of  the  liver 
upon  the  colon  bacillus.  Lemaire  points  out  that,  according  to  Wyssok- 
witch,  the  liver  excretes  microbes  with  the  bile,  whereas  Werigo  and  others 
claim  that  the  liver  destroys  them  directly  by  virtue  of  the  phagocytic 
action  of  its  endothelial  cells,  which  either  englobe  the  microbes  directly 


xs.=.^>; 


&  m 


Fig.  97.— 1,  white  corpuscles  from  normal  blood;    2,  pus-corpuscles  with  cocci  in  tlieir 
interior;    3,  pus-corpuscles  with  bacilli  in  their  interior.     (Koch.) 

or  receive  them  from  the  leucocytes  of  the  blood.  It  is  the  function  of 
the  endothelial  cells  of  the  liver  to  prevent  or  retard  general  infection 
with  the  colon  bacillus,  and  a  colon  bacillus  which  produces  general  in- 
fection is  one  which  the  cells  of  the  liver  cannot  destroy.  This  general 
conclusion  is  supported  by  the  results  of  the  study  of  phenomena  produced 
by  injection  of  colon  bacilli  in  rabbits  immunized  by  means  of  anticolon- 
bacillus  serum.  The  immunized  animals  all  survived  the  injection  of  such 
quantities  of  both  kinds  of  colon  bacilli  as  was  fatal  for  the  control  ani- 
mals. The  blood  of  the  immunized  animals  remained  sterile,  as  did  the 
spleen  and  the  bone-marrow.  Careful  microscopical  examination  failed  to 
reveal  phagocytosis  on  the  part  of  the  leucocytes;  the  only  place  in  which 
bacilli  were  foimd  was  in  the  liver,  and  the  small  number  present  indi- 
cated that  ultimately  total  destruction  of  all  bacilli  would  have  taken 


240  PEINCIPLES    OF    SUEGERY. 

place,  showing  that  the  antiinfectious  serum  aids  the  action  of  the  endo- 
thelial cells  of  this  organ.  Hektoen  believes  that  in  the  retardation  or 
prevention  of  colon-bacillus  infection  a  direct  chemical  action  between  the 
antiserum  and  the  toxins  of  the  colon  bacillus  takes  an  important  part. 
The  surgeon  meets  most  frequently  with  colon-bacillus  infection  in  the 
treatment  of  perforative  peritonitis  and  cystitis,  but  there  is  no  organ 
or  part  of  the  body  exempt  from  infection  with  this  intestinal  microbe. 

IV.    PUS. 

Pus  is  the  liquefied  product  of  suppurative  inflammation.  It  can  be 
defined  as  a  dead  or  dying  tissue  composed  of  cells  with  a  fluid  intercellular 
substance.  Pus  is  an  opaque,  creamy,  yellowish-white  or  greenish-white 
fluid,  which,  in  a  recent  state,  shows  a  slightly-acid  reaction,  and,  later, 
becomes  alkaline  by  the  formation  of  ammonia.  If  it  is  of  a  yellowish 
color,  creamy  consistence,  and  odorless,  it  is  the  pus  honum  vel  laudahile 
of  the  old  authors.  If  it  is  thin  and  intimately  mixed  with  blood  it  is 
called  sanious  or  ichorous  pus.  If  it  contain  but  few  pus-corpuscles  and 
resembles  serum,  we  speak  of  serous  pus.  Pus  undergoing  putrefaction 
from  the  presence  of  saprophytic  bacteria  is  rendered  fetid,  and  is  then 
termed  fetid  pus.  Pus  mixed  with  the  products  of  tubercular  inflamma- 
tion is  designated  tubercular  pus,  and  if  mixed  with  the  secretion  of  an 
inflamed  mucous  membrane  it  is  defined  as  muco-pus.  If  pus  is  allowed 
to  stand  undisturbed  for  a  number  of  hours  in  a  test-tube,  it  separates  into 
two  parts:  the  upper,  the  liquid  portion,  is  the  pus-serum,  or  liquor  puris, 
while  the  lower  represents  the  solid  constituents  of  the  pus,  the  pus- 
corpuscles. 

Pus-senim. — The  pus-serum  contains  albumen,  a  compound  called 
pyine,  regarded  by  Mulder  as  identical  with  tritoxide  of  protein,  occasion- 
ally chondrin,  glutin,  and  leucin,  abundant  fatty  matter,  and  inorganic 
substances  similar  to  those  dissolved  in  the  liquor  sanguinis.  Pus-serum 
contains  no  oxygen  or  hydrogen,  or  if  present  these  gases  are  found  only 
in  minute  quantities.  On  the  other  hand,  it  contains  nitrogen  and  car- 
bonic acid  in  large  amounts.  It  contains  more  potash  and  soda  than  blood- 
serum.  Among  the  albuminous  substances  which  it  contains  are  para- 
globin,  albuminate  of  potash,  serum,  albumen,  and  myosin.  Pus-serum, 
in  fact,  is  liquor  sanguinis  plus  soluble  compounds  which  have  developed 
during  the  inflammatory  process;  hence  it  also  contains  in  solution  the 
toxins  elaborated  by  the  pus-microbes. 

Pus-corpuscles. — The  histological  sources  of  pus-corpuscles  are  the 
leucocytes  and  embryonal  cells.  In  acute  inflammation  the  process  is  so 
rapid  that  the  pus-corpuscles  are  derived  almost  exclusively  from  leuco- 
cytes.   The  conversion  of  a  leucocyte  into  a  pus-corpuscle  in  clinical  sup- 


PUS.  241 

puration  is  invariably  accomplished  by  one  or  more  kinds  of  pus-microbes, 
which  have  been  described.  The  pus-microbes  constitute  the  most  im- 
portant morphological  element  of  the  product  of  suppurative  inflamma- 
tion, being  not  only  diffused  between  the  cells,  but  also  finding  their  way 
into  the  interior  of  the  cells. 

All  pus-corpuscles  show  structural  changes  which  indicate  disintegra- 
tion. The  leucocytes  present,  as  the  first  evidence  of  transformation  into 
pus-corpuscles,  fragmentation-  of  the  nucleus. 

Nuclear  fragmentation  is  an  entirely  different  process  from  karyo- 
kinesis,  as  it  is  not,  like  the  latter,  an  indication -of  cell-reproduction,  but 


■- ' '  '        (^f^  ;^  •  (  ycj   ■^"' 


Fig.   98. — Fragmentation  of  Nucleus  in  Leucocytes  undergoing  Transformation  into 
Pus-corpuscles.    (Hartnack  8,  oc.  iv.)     (Landerer.) 

of  cell-destruction.  The  nucleus  breaks  up  into  two  to  six  or  more  frag- 
ments, the  cell-body  still  retaining  its  original  form.  Fragmentation  of 
the  nucleus  is  attended  by  other  forms  of  intracellular  disintegration. 
The  protoplasmic  strings,  which  form  a  living  reticulum  in  the  interior 
of  the  nucleus  and  cell-body,  break  up  and  disintegrate.  The  embryonal 
cells  which  are  converted  into  pus-corpuscles  undergo  similar  retrograde 
changes  as  have  been  described  in  the  leucocyte.  Pus-corpuscles  are  not 
always  of  the  same  size  and  shape.  Their  size  depends  on  their  histolog- 
ical source.  Those  derived  from  leucocytes  are  somewhat  uniform  in  size, 
while  in  subacute  and  chronic  suppuration  the  fixed  tissue-cells  in  a  state 
of  proliferation  furnish  a  large  percentage  of  the  pus-corpuscles,  and  con- 


242 


PEINCIPLES    OF    SURGEEY. 


sequently  their  size  varies  according  to  the  tissue-cells  which  undergo  this 
change.  As  long  as  the  leucocytes  or  embryonal  tissue-cells  are  not  com- 
pletely destroyed  by  the  pus-microbes  or  their  toxins,  they  vary  greatly 
in  their  shape.  The  variation  in  shape  in  fresh  pus-corpuscles  which  have 
not  completely  succumbed  to  the  pus-microbes  is  due  to  their  amoeboid 


BWIm..-:-^«^r 


Fig.  99.  Fig.  100. 

Fig.  99.— Pus  with  Staphylococcus.     X  800.     (Fluegge.) 
Fig.  100. — Pus  with  Streptococcus.     (Fluegge.) 

movements.  If  pus  from  an  acute  abscess  is  examined  in  a  moist  chamber 
upon  a  warm  slide,  the  amoeboid  movements  of  the  pus-corpuscles  can  be 
observed  for  hours,  provided  the  slide  is  kept  at  a  proper  temperature. 

Pus-corpuscles  subjected  to  the  action  of  acetic  acid  clear  up  and 
show  their  fragmented  nucleus  much  plainer.  If  pus-corpuscles  are  mixed 
with  water  they  become  larger  and  hydropic  from  inhibition  of  fluids.    The 


(0) 


Fig.  101. — 1,  dead  pus-corpuscles;  2,  various  forms  which  living  pus-corpuscles 
assume  by  their  amoeboid  movements;  3,  pus-corpuscles  acted  upon  by  acetic  acid;  4, 
pus-corpuscles  after  addition  of  water.     X  400.     {Billroth-Winiwarter.) 

round  pus-corpuscles,  according  to  Eecklinghausen,  are  dead  leucocytes 
or  embryonal  cells  which  have  lost  their  amoeboid  movements.  Liquor 
potassa  dissolves  the  pus-corpuscles,  and,  if  added  to  fluids  containing  pus, 
changes  them  into  a  gelatinous  mass.  In  chronic  abscesses  the  pus- 
corpuscles  undergo  molecular  degeneration,  and  such  pus  under  the  micro- 
scope shows  no  well-formed  corpuscles,  but  a  mass  of  granular  detritus. 


PUS.  243 

If  the  serum  is  absorbed,  we  speak  of  inspissation  of  pus.  If  a  wall  of  cica- 
tricial tissue  form  around  a  collection  of  pus,  we  say  that  the  pulse  has 
become  encysted  or  encapsulated. 

Blue  Pus. — Blue  pus  is  produced  by  the  bacillus  pyocyaneus:  a  com- 
paratively mild  pus-microbe  possessing  chromogenic  properties.  The 
coloring  material  is  imparted  to  pure  cultures  and  the  dressings  used  in 
the  treatment  of  suppurating  wounds  in  which  this  microorganism  is  the 
principal  cause  of  suppuration. 

Red  Pus. — Eed  pus  has  recently  been  described  by  Ferchmin.  It  is 
caused  by  a  chromogenic  bacillus  whose  length  is  about  one-third  of  the 
diameter  of  a  red  blood-corpuscle.  The  bacillus  is  non-motile  and  color- 
less, but  is  readily  stained  by  Gram's  method.  It  can  best  be  cultivated 
upon  blood-serum;  the  cultures  have  a  bright-red  color,  which  later 
changes  to  violet. 


CHAPTEE  X. 

SuppuEATiON  (continued). 

CLIlSriCAL    POEMS    OF    SUPPUEATIOlSr. 

In  reference  to  the  time  required  to  transform  the  product  of  inflam- 
mation into  pus,  suppuration  can  be  divided  into  acute,  subacute,  and 
chronic. 

1.  Acute  Suppuration. — In  acute  suppuration  the  wall  of  the  capillary 
vessels  is  altered  so  seriously  that  emigration  of  the  colorless  corpuscles 
takes  place  with  such  rapidity  that  within  a  few  hours  the  connective- 
tissue  spaces  are  crowded  with  them,  and  in  a  few  days  the  inflammatory 
swelling  presents  indications  of  approaching  suppuration.  The  inflam- 
matory product  is  hard  to  the  touch,  and  the  tissues  around  it  become 
oedematous  from  obstruction  to  the  plasma-circulation  within  and  in  the 
immediate  vicinity  of  the  inflamed  tissues.  The  hardness  of  the  swelling 
is  due  to  the  infiltration  of  the  connective  tissue  with  leucocytes.  In 
this  form  of  suppuration  a  central  ischgemic  area  is  established  by  the 
rapid  accumulation  of  leucocytes  in  the  connective-tissue  spaces  and  by 
pressure  upon  the  inflamed  and  weakened  capillary  vessels,  which  finally 
leads  to  complete  stasis.  The  pus-microbes  and  preformed  toxins  are 
present  in  such  large  quantities  that  liquefaction  of  the  inflammatory 
product  takes  place  within  a  few  days.  The  first  appearances  of  suppura- 
tion are  observed  among  the  cellular  elements  which  appeared  first,  which 
corresponds  to  a  point  in  the  centre  of  the  infiammatory  swelling,  because 
at  this  point  tissue-nutrition  has  suffered  most  and  the  inflammatory 
product  has  been  exposed  longest  to  the  deleterious  action  of  the  pus- 
microbes  and  their  toxins.  The  direct  causes  of  conversion  of  leucocytes 
into  pus-corpuscles  are  the  pus-microbes  and  their  toxins,  the  pathogenic 
action  of  which  on  the  tissues  results  in  purulent  liquefaction  of  the  in- 
flammatory product.  Softening  in  the  centre  of  an  inflammatory  swelling 
is  almost  an  unerring  sign  of  approaching  suppuration.  The  central  sup- 
purating focus  increases  in  size  by  the  extension  of  the  process  of  liquefac- 
tion in  all  directions,  the  leucocytes  saturated  with  the  toxins  of  the  pus- 
microbes  being  rapidly  transformed  into  pus-corpuscles.  Acute  suppura- 
tion is  always  accompanied  by  more  or  less  necrosis  of  the  fixed  tissue- 
cells.  The  acute  cell-necrosis  is  the  result  of  diminished  blood-supply 
and  the  local  toxic  effect  of  the  chemical  products  of  the  pus-microbes. 
Necrosis  occurring  so  constantly  from  the  combined  action  of  these  two 
etiological  factors  in  acute   suppurative  osteomyelitis  furnishes   a  good 

(244) 


CLINICAL   FORMS    OF    SUPPURATION.  '  245 

illustration  of  this.  In  phlegmonous  inflammation,  from  the  smallest 
furuncle  to  the  largest  acute  abscess,  connective-tissue  necrosis  is  a  con- 
stant occurrence,  following  as  an  unavoidable  sequence  of  acute  suppura- 
tion. Acute  suppuration  is  almost  without  exception  attended  by  a  com- 
plexus  of  symptoms,  indicating  the  entrance  of  phlogistic  substances  from 
the  inflamed  tissues  into  the  general  circulation, — such  as  fever,  headache, 
thirst,  loss  of  appetite, — which  usually  subside  with  the  removal  of  the 
primary  cause.  Acute  osteomyelitis,  acute  suppurative  inflammation  of 
the  large  serous  cavities  and  joints,  and  phlegmonous  inflammation  of  dif- 
ferent organs  are  excellent  examples  of  what  is  understood  by  acute  sup- 
puration, from  an  etiological,  pathological,  and  clinical  stand-point. 

2.  Subacute  Suppuration. — As  acute  inflammation  may  pass  into  a 
subacute  form,  so  suppuration  may  be  delayed  in  acute  inflammation  for 
days  and  weeks,  if  the  indirect  and  direct  causes  which  are  concerned  in 
the  transformation  of  the  cellular  elements  into  pus-corpuscles  are  present, 
less  in  degree  and  intensity  than  in  acute  suppuration.  The  character 
and  intensity  of  the  primary  microbic  cause  may  determine  a  subacute 
type  of  inflammation  from  the  beginning,  and  suppuration  is  correspond- 
ingly delayed.  In  subacute  suppuration  the  tissues  have  more  time  to 
accommodate  themselves  to  the  presence  of  the  inflammatory  exudate, 
and  hence  tissue-necrosis  is  a  less  constant  occurrence,  and,  if  present,  it 
is  less  extensive.  In  subacute  suppuration,  at  least,  a  part  of  the  pus- 
corpuscles  are  derived  from  the  flxed  tissue-cells;  while  in  acute  suppura- 
tion central  liquefaction  of  the  inflammatory  product  may  take  place 
within  three  or  four  days,  the  same  stage  in  the  subacute  form  is  often 
not  attained  in  as  many  weeks.  As  a  rule,  the  general  symptoms  are  also 
less  severe. 

3.  Chronic  Suppuration. — In  acute  and  subacute  suppuration  the  pus- 
corpuscles  are  derived,  in  the  former  almost  exclusively,  and  in  the  latter 
largely,  from  the  extravasated  leucocytes.  With  few  exceptions,  chronic 
suppuration  occurs  as  the  result  of  infection  with  pus-microbes  of  a 
preexisting  pathological  product  composed  of  granulation-tissue.  In  such 
cases  the  embryonal  tissue  is  the  product  of  a  specific  inflammation  caused 
by  the  presence  of  microorganisms  which  possess  no  pyogenic  properties, 
but  which  excite  in  the  tissues  a  chronic  inflammation,  the  product  of 
which  consists  of  granulation-tissue.  The  bacillus  of  tuberculosis,  the 
microbe  of  syphilis,  and  the  actinomyces  are  good  illustrations  of  this 
class  of  microbes.  If  a  lesion  caused  by  any  of  these  microbes  become  the 
seat  of  infection  with  pus-microbes,  the  latter  and  their  toxins  are  brought 
in  contact  with  cells  which  are  readily  converted  into  pus-corpuscles.  In 
chronic  suppuration  the  pus-corpuscles  are  derived  mostly  from  embryonal 
cells,  and  consequently  they  show  a  greater  variety  in  size  and  shape  than 


246  PEINCIPLES    OF    SURGERY. 

the  pus-corpuscles  found  in  an  acute  abscess.  Purulent  liquefaction  of  a 
mass  of  granulation-tissue  is  the  characteristic  pathological  feature  of  chronic 
suppuration.  Embryonal  cells  derived  from  any  of  the  fixed  tissue-cells  are 
converted  into  pus-corpuscles  by  the  pus-microbes  and  their  toxins  in  the 
same  manner  as  the  leucocytes  in  an  acute  abscess,  only  that  this  result  is 
attained  more  slowly.  In  the  majority  of  cases  chronic  suppuration  is  the 
result  of  infection  with  pus-microbes  of  a  preexisting  granulating  focus,  the 
liquefied  portion  of  which  constitutes  the  contents  of  the  chronic  abscess. 
While  an  acute  abscess  is  often  developed  in  the  course  of  a  few  days,  and  a 
subacute  in  as  many  weeks,  it  may  require  as  many  months  or  years  for  the 
products  of  a  specific  inflammation  to  be  transformed  into  a  chronic  abscess. 

Chronic  suppuration  solely  due  to  the  pathogenic  effects  of  pus- 
microbes  is  seen  most  frequently  in  the  lymphatic  glands  of  the  neck  and 
axillary  spaces.  The  glands  thus  afEeeted  enlarge  very  slowly,  pain  and 
tenderness  are  slight  and  several  months  may  elapse  before  the  centre  of 
the  inflamed  gland  is  converted  into  an  abscess-cavity.  We  must  take  it 
for  granted  that  in  chronic  suppurative  parenchymatous  lymphadenitis 
the  infection  is  caused  by  a  comparatively  small  number  of  pus-microbes 
or  that  the  microbes  possess  feeble  pyogenic  properties.  In  the  differen- 
tial diagnosis  of  chronic  affections  of  isolated  lymphatic  glands  chronic 
suppurative  inflammation  should  always  be  borne  in  mind. 

Suppuration  in  Wounds.^ — Infection  of  a  recent  wound  with  a  suffi- 
cient number  of  pus-microbes  is  followed  by  suppurative  inflammation, 
which  in  its  local  and  general  manifestations  resembles  phlegmonous  in- 
flammation as  it  occurs  without  a  wound.  One  of  the  earliest  evidences 
that  such  infection  has  taken  place  is  a  profuse  primary  wound-secretion. 
This  secretion  is  a  mixture  of  blood  and  serum,  and  is  secreted  in  excess 
on  account  of  the  inflamed  capillaries  being  more  permeable,  and  yielding 
more  readily  to  the  intravascular  pressure.  It  is  also  possible  that  under 
these  circumstances  closure  of  the  lumen  of  divided  capillary  vessels  does 
not  take  place  as  promptly  nor  as  completely  as  in  aseptic  wounds.  Sup- 
purative inflammation,  when  it  attacks  a  recent  wound,  commences  upon 
its  surface,  with  which  the  microbes  have  been  brought  in  contact,  and 
the  products  of  coagulation-necrosis  furnish  a  favorable  soil  for  their 
growth  and  reproduction.  In  such  a  wound  the  process  of  granulation  is 
either  impeded  or  completely  suspended  until  the  acute  symptoms  have 
subsided,  as  the  embryonal  cells  are  converted  into  pus-corpuscles  almost 
as  soon  as  they  are  formed.  From  the  surface  of  the  wound  the  inflam- 
mation extends  to  the  deeper  tissues,  the  extension  being  usually  along 
the  connective  tissue,  fascia,  and  intermuscular  septa.  The  parts  in  the 
immediate  vicinity  of  the  wound  present  the  usual  appearances  of  a  phleg- 
monous inflammation.     The  pus  which  forms  first  contains  dead  leuco- 


SUPPURATIVE    INFLAMMATION    OF    MUCOUS    MEMBEANES.  347 

cytes,  while  later  the  embryonal  cells  furnish  an  additional  histological 
source  for  pus-corpuscles.  Aseptic  granulating  wounds  are  usually  con- 
sidered exempt  from  infection  with  pus-microbes.  While  this  may  be  true 
if  the  whole  surface  is  covered  with  an  uninterrupted^  intact  layer  of 
healthy  granulations,  it  is  certainly  not  the  case  if  the  granulations  are 
in  any  way  injured  or  diseased.  A  slight  injury,  as  probing,  may  create 
an  infection-atrium,  through  which  pus-microbes  enter  the  deeper  tis- 
sues, where  they  may  become  the  cause  of  a  suppurative  inflammation. 
Under  unfavorable  vascular  conditions  the  granulations  are  rendered 
hydropic,  become  flabby  and  anagmic, — conditions  which  impair  their  re- 
sistance to  the  action  of  pus-microbes, — which  then  convert  the  layer  of 
embryonal  cells  most  remote  from  the  blood-supply  into  pus-corpuscles. 
The  preformed  toxins  injure  the  subadjacent  cells,  which,  in  turn,  undergo 
the  same  fate,  and  thus  an  unhealthy,  infected  granulation  surface  be- 
comes the  cause  of  a  secondary  suppuration  in  wounds  which  indefinitely 
delays  the  healing  process.  If  in  a  suppurating  wound  the  pus-microbes 
attack  a  vein  and  produce  a  septic  thrombophlebitis,  the  essential  etio- 
logical condition  for  the  occurrence  of  the  most  dangerous  and  intractable 
complication,  pysemia,  has  been  established. 

The  disinfection  of  a  suppurating  wound  still  remains  an  opprobrium 
in  surgery.  The  most  faithful  attempts  to  transform  a  septic  into  an 
aseptic  wound  seldom  succeed.  This  has  led  some  surgeons  to  advo- 
cate and  practice  asepsis  rather  than  antisepsis.  Zeidler  holds  that  the 
experiments  of  Schimmelbusch  confirm  the  belief  he  long  entertained, 
that  it  is  practically  impossible  to  destroy  the  organisms  which  have 
entered  a  wound.  He  thoroughly  dissects  out  all  pus-infiltrated  tissues, 
wipes  with  sterile  gauze,  irrigates  with  a  6-per-cent.  saline  solution,  packs 
lightly  with  sterile  gauze,  and  applies  a  dry,  sterile  dressing,  and  when 
this  becomes  saturated  he  changes  the  outer  dressing  without  removing 
the  packing.  This  treatment  is  applicable  when  the  wound  is  not  large 
and  advantageously  located;  in  other  cases  the  antiseptic  treatment  must 
be  relied  upon. 

SUPPURATIVE    INFLAMMATION    OF    MUCOUS    MEMBRANES. 

Suppurative  inflammation  of  a  mucous  membrane  is  always  preceded 
by  a  catarrhal  stage,  during  which  the  amount  of  the  physiological  secre- 
tion is  greatly  increased.  Proliferation  of  epithelial  cells  takes  place  with 
such  great  rapidity  that  the  blood-supply  becomes  inadequate,  when  the 
most  superficial  embryonal  cells  readily  succumb  to  the  specific  action 
of  the  pus-microbes  and  are  exfoliated  as  pus-corpuscles.  The  toxins  be- 
come diffused  in  advance  of  the  microbic  invasion,  and,  by  injuring  the 
protoplasm  of  the  cells  more  deeply  located,  prepare  the  way  for  the 


248  PRINCIPLES    OF    SURGERY. 

pathogenic  action  of  the  pus-microbes,  and  suppuration  extends  more 
deeply.  In  this  way  ulcers  form,  which  may  remain  superficial,  or  which 
may  also  penetrate  deeply  and  result  in  perforation.  The  products  of 
coagulation-necrosis  which  form  upon  the  surface  of  an  inflamed  mucous 
membrane  favor  the  occurrence  and  extension  of  suppurative  lesions,  as 
they  serve  as  a  means  of  fixation  and  propagation  of  the  pus-microbes. 
Pus  from  a  suppurating  mucous  membrane,  examined  microscopically, 
will  show  pus-corpuscles  derived  from  leucocytes  and  embryonal,  epi- 
thelial, and  connective-tissue  cells  which  have  become  detached  before 
they  are  converted  into  pus-cells. 

ABSCESS. 

An  abscess  is  a  collection  of  pus  in  the  tissues.  A  collection  of 
pus  in  a  preformed  space,  such  as  the  pleura,  pericardium.  Fallopian 
tubes,  pelves  of  kidneys,  etc.,  although  resulting  from  a  suppurative 
inflammation  of  the  walls  lining  the  space,  is  by  general  custom  and 
usage  not  called  an  abscess,  but  the  presence  of  pus  in  any  of  these  organs 
is  indica,ted  by  the  prefix  pyo,  to  which  is  added  the  anatomical  locality: 
thus,  pyothorax,  py ©pericardium,  pyosalpinx,  pyonephrosis.  The  forma- 
tion of  an  abscess  is  always  preceded  by  a  circumscribed  suppurative  in- 
flammation. The  histological  conditions  which  are  present  at  the  time 
pus-formation  commences  are  characterized  by  a  richness  of  leucocytes  in 
the  connective  tissue  between  the  inflamed  capillary  vessels  and  compres- 
sion of  the  preexisting  tissue-cells  by  them  and  the  transuded  serum. 

Suppuration  commences  at  one  or  more  points  in  the  infiltrated  area; 
if  the  latter  is  the  case,  the  different  suppurating  foci  soon  become  conflu- 
ent, forming  an  abscess-cavity,  which  increases  in  size  in  all  directions, 
both  by  the  products  of  inflammation  breaking  down  into  pus  and  by  the 
mechanical  pressure  of  the  exudation  and  transudation  upon  the  sur- 
rounding tissues.  Cheyne,  in  his  excellent  article  on  suppuration,  de- 
scribes the  changes  which  precede  and  attend  abscess-formation  as  fol- 
lows: "Staining  sections  of  tissue  in  which  these  plugs  are  present  with 
ordinary  aniline  dyes,  it  is  found  that,  Avhile  the  mass  of  organisms  is 
internally  stained,  and  while  the  nuclei  in  the  sections  have  become  well 
colored,  there  is  a  ring  of  tissue  around  the  central  mass  of  organisms 
which  does  not  take  in  the  stain  and  which  presents  an  homogeneous,  trans- 
lucent appearance.  This  ring  evidently  results  from  the  action  of  the 
concentrated  products  of  the  micrococci,  the  tissues  being  brought  into 
the  condition  of  coagulation-necrosis.  After  some  hours  a  second  ring 
appears  at  a  greater  distance  from  the  mass  of  organisms,  this  ring  being 
composed  of  a  dense  layer  of  leucocytes  apparently  collecting  where  the 
chemical  substances  are  more  dilute  and  do  not  interfere  with  the  life  of 


ABSCESS. 


249 


the  cells.  The  abscess  forms  by  the  central  softening  of  the  inflamma- 
tory product  and  increases  by  the  successive  formation  of  additional  rings, 
which  undergo,  in  turn,  coagulation-necrosis  and  suppuration."  The  size 
of  the  abscess  is  determined  by  the  nature  of  the  primary  cause  of  the 
inflammation,  its  location,  and  the  degree  of  local  and  general  resistance 
inherent  in  the  tissues  and  the  patient.  The  staphylococcus  is  found  more 
frequently  in  circumscribed  abscesses,  while  the  streptococcus  is  more 
prone  to  give  rise  to  diffuse  purulent  infiltration.  A  suppurating  focus 
near  a  surface  is  not  so  likely  to  result  in  a  large  abscess  as  when  it  is 
more  deeply  located,  as  in  the  former  case  spontaneous  evacuation  in  the 
direction  offering  the  least  resistance  is  an  early  occurrence,  while  in  the 
latter  instance  such  a  termination  is  only  possible  after  the  abscess  has 
reached  considerable  dimensions.     An  abscess  which  develops  in  tissues 


Fig.  102.— Infiltration  of  Connective  Tissue  of  Cutis,  with  Beginning  Suppuration 
in  the  Centre.    X  500.     (Billroth-Winiwarter.) 

debilitated  by  a  contusion  or  some  antecedent  lesions  usually  reaches 
greater  dimensions  than  if  it  occur  in  otherwise  healthy  tissues.  In  pa- 
tients whose  strength  has  been  impaired  by  old  age,  improper  or  insuffi- 
cient food,  intemperance,  mental  anxiety,  or  some  antecedent  acute  or 
chronic  ailment  it  is  well  known  that  acute  suppurative  inflammation 
manifests  a  great  tendency  to  rapid  extension;  while  a  vigorous,  healthy 
body  offers  the  most  favorable  conditions  toward  limitation  of  the  sup- 
purative inflammation.  While  liquefaction  of  the  inflammatory  product 
progresses  from  the  centre  toward  its  periphery,  the  outer  zone  of  the 
inflamed  area  is  in  a  condition  of  hypersemia  and  active  tissue-proliferation. 
The  leucocytes  beyond  the  infected  area  are  not  converted  into  pus-corpus- 
cles, and  with  the  products  of  tissue  proliferation  constitute  an  impermeable 
wall,  beyond  which  infection  cannot  extend.    The  limit  of  the  abscess  is  an 


250 


PRINCIPLES    OF    SURGERY. 


aseptic  zone  of  infiltration,  clinically  readily  recognized  by  its  hardness  to 
the  sense  of  touch:  the  so-called  abscess-wall.  As  many  of  the  small  vessels 
in  the  centre  of  the  abscess  are  permanently  destroyed,  a  collateral  circula- 
tion is  established  in  the  absc„ess-wall  and  its  immediate  vicinity  by  the 
formation  of  new  vessels,  as  is  well  shown  in  Fig.  103. 

According  to  their  contents,  the  causes,  and  the  time  which  elapsed 
between  the  commencement  of  the  disease  which  caused  them  and  their 
formation,  abscesses  are  divided  into  acute  and  chronic. 

Acute  Abscess. — The  acute,  or  hot,  abscess  is  the  usual  termination 
of  acute,  circumscribed,  suppurative  inflammation.  Its  favorite  location 
is  in  the  connective  tissue.  It  is  always  caused  by  infection  with  pus- 
niicrobes,  most  frequently  the  staphylococcus.    It  contains  the  character- 


Fig.  103.— Vessels  (Artificially  Injected)   from  Walls  of  an  Abscess  Artificially- 
Produced  in  the  Tongue  of  a  Dog.     X  25.     (Billroth-Winiwarter.) 

istic  yellowish,  creamy  pus,  the  pus  honum  vel  laudibile  of  the  old  authors, 
and  shreds  of  necrosed  connective  tissue.  It  appears  within  a  few  days 
after  the  commencement  of  the  inflammation  and  reaches  its  maximum 
size  in  a  short  time.  It  is  attended  by  the  typical  local  and  general  symp- 
toms which  accompany  acute  suppurative  inflammation.  Acute  abscess  in 
the  abdominal  cavity  usually  develops  after  perforation  of  the  intestine 
or  one  of  its  appendages;  thus,  perforation  of  the  gall-bladder  often  gives 
rise  to  circumscribed  suppuration  between  the  liver,  stomach,  and  colon, 
and  perforation  of  the  appendix  vermiformis  in  the  right  iliac  region,  where 
the  circumscribed  collection  of  pus  is  called  a  perityphlitic  abscess.  The 
loose  connective  tissue  that  surrounds  the  kidney  is  often  the  seat  of  an 
acute  suppurative  inflammation,  giving  rise  to  a  perinephritic   abscess. 


ABSCESS.  251 

The  connective  tissue  in  front  of  the  bladder,  the  so-called  cavum  Retzii, 
when  it  is  infected  with  pus-microbes,  occasionally  becomes  the  starting- 
point  of  an  acute  abscess.  In  three  cases  of  abscess  in  this  locality,  that 
came  under  my  observation,  the  infection  was  caused  by  a  perforation  of 
an  intestine,  and  in  all  of  them,  after  incision,  scraping,  disinfection,  and 
drainage,  a  fffical  fistula  developed  subsequently.  Su.ppurative  parame- 
tritis is  another  instance  of  acute  abscess,  and  is  usually  caused  by  in- 
fection through  the  uterine  cavity  or  the  Fallopian  tubes.  Perirectal 
abscesses  following  suppurative  paraproctitis  are  frequently  preceded  by 
localized  rectal  lesions,  through  which  infection  of  the  connective  tissue 
surrounding  the  rectum  with  pus-microbes  takes  place.  The  manner  of 
invasion  often  determines  the  location  and  character  of  the  abscess.  Thus,  in 
suppurative  mastitis  the  abscesses  which  are  caused  by  staphylococci  al- 
ways begin  in  the  deeper  part  of  the  organ  and  extend  toward  the  sur- 
face, while  in  infection  with  streptococci  of  the  same  part  the  inflamma- 
tion starts  from  some  superficial  abrasion  and  first  attacks  the  skin, 
whence  the  process  extends  in  a  central  direction  to  the  deeper  portions 
of  the  gland,  where  suppuration  takes  place  (Cheyne).  This  difference 
depends  on  the  manner  of  invasion  of  the  two  microbes.  The  staphylo- 
cocci enter  the  organism  through  the  milk-ducts  and  act  from  their  in- 
terior; whereas  the  streptococci,  like  the  microbe  of  erysipelas,  enter  the 
tissues  through  the  lymphatic  vessels,  and  their  pathogenic  action  is  pri- 
marily observed  at  the  surface.  Bumm  excised  a  portion  of  the  wall  of  a 
commencing  abscess  of  the  breast,  and  was  able  to  demonstrate  the  pres- 
ence of  staphylococci  in  the  interior  of  the  acini,  and  their  penetration 
thence  into  the  interacinous  tissue.  The  phlegmonous  inflammation  of 
the  breast  caused  by  streptococci  takes  place  along  the  course  of  the  lym- 
phatics, and  primarily  involves  the  interacinous  connective  tissue.  ■ 

Diagnosis. — The  recognition  of  an  acute  abscess  is  usually  not  at- 
tended by  any  great  difficulties.  The  history  of  an  attack  of  acute  sup- 
purative inflammation  is  the  first  thing  to  be  taken  into  consideration. 
Fever  is  usually  present,  but  if  the  abscess  has  been  caused  by  the  micro- 
coccus pyogenes  tenuis  it  may  be  slight  or  entirely  absent.  The  location 
of  the  abscess  has  also  considerable  influence  on  the  temperature.  There 
is  no  doubt  that  the  same  kind  and  number  of  pus-microbes  in  some  tis- 
sues produce  either  a  larger  quantity  of  phlogistic  substances,  or  that  these 
in  some  localities  and  certain  tissues  find  a  more  ready  entrance  into  the 
circulation.  Pain  is  always  present,  but  is  variable  in  intensity  according 
to  the  location  of  the  abscess  and  the  nature  of  its  surroundings.  It  is 
severe  if  the  abscess  involve  parts  freely  supplied  with  sensitive  nerves, 
and  where  the  inflammatory  product  gives  rise  to  an  unusual  degree  of 
tension.    Thus,  a  small  abscess  underneath  the  deep  fascia  of  a  finger  will 


252  PEINCIPLES    OF    SUEGEKY. 

cause  more  suffering  than  a  large  abscess  in  loose  connective  tissue.  A 
beginning  abscess  can  usually  be  accurately  located  by  ascertaining  the 
exact  point  of  tenderness  on  making  pressure  with  the  tip  of  a  finger.  If 
the  abscess  is  sufficiently  near  the  surface,  fluctuation  can  be  felt  as  soon 
as  central  liquefaction  has  occurred.  Eedness  of  the  skin  and  diffuse 
oedema  over  and  around  the  abscess  are  important  symptoms,  denoting 
the  presence  of  pus.  Eemembering  all  the  symptoms  which  point  to  the 
existence  of  abscess,  in  doubtful  cases  an  absolute  diagnosis  should  not  be 
made  by  relying  upon  any  one  or  all  of  them,  as  by  doing  so  serious  blun- 
ders have  been  and  will  be  made  in  treatment.  Aneurisms  have  been  in- 
cised under  the  belief  that  they  were  abscesses,  and  the  less  serious  mis- 
take has  been  made  of  treating  an  abscess  for  an  aneurism.  The  late 
Professor  Gunn,  who  was  well  known  as  a  careful  and  clever  diagnostician, 
incised  a  large  angioma  in  the  occipital  region^  having  mistaken  it  for  an 
abscess.  An  inflammatory  swelling  occurring  in  localities  where  aneu- 
risms are  liable  to  be  met  with — that  is,  in  the  course  of  large  blood-vessels 
— should  be  examined  with  the  utmost  care  before  an  incision  is  made. 
The  most  difficult  cases  for  diagnosis  are  the  few  instances  where  a  sup- 
purative inflammation  occurs  around  an  aneurismal  sac.  Fortunately,  we 
are  in  possession  of  a  very  simple  diagnostic  expedient,  which,  if  resorted 
to,  as  it  should  be,  in  all  doubtful  cases,  will  enable  the  surgeon,  with  in- 
fallible certainty,  to  ascertain  the  presence  or  absence  of  pus  in  an  in- 
flammatory swelling,  and  this  is  the  use  of  the  exploring  syringe.  An 
ordinary  hypodermic  needle  with  a  long  point  will  answer  the  purpose, 
although  every  surgeon  should  be  supplied  with  an  exploring  syringe  made 
for  this  special  purpose.  The  needle  must  be  rendered  thoroughly  aseptic 
by  heating  it  in  the  flame  of  an  alcohol-lamp,  or,  still  better,  by  boiling  in 
soda  solution  (1  per  cent.).  The  surface  where  the  puncture  is  to  be  made 
is  thoroughly  disinfected,  and  the  needle  is  inserted  somewhat  obliquely 
toward  the  centre  of  the  swelling  and  pushed  boldly  forward  in  this  di- 
rection until  resistance  ceases,  which  is  an  indication  that  it  has  reached 
a  cavity;  the  piston  of  the  syringe  is  now  slowly  withdrawn  and  the  fluid 
aspirated  is  examined;  if  it  is  pus  the  diagnosis  is  made  and  the  needle  is 
withdrawn.  If  no  pus  is  found  the  exploration  is  carried  deeper,  and,  if 
necessary,  in  different  directions  without  removing  the  needle,  by  making 
aspiration  at  different  points  so  as  to  explore  fully  the  tracks  made  by 
the  needle.  If  no  positive  diagnosis  can  be  made  it  may  become  necessary 
to  repeat  this  method  of  examination  in  a  few  days.  A  rapidly-growing 
sarcoma  may  simulate  a  suppurative  inflammation  so  closely  that  great 
care  is  necessary  to  distinguish  between  these  affections  before  any  opera- 
tive procedure  is  advised  or  undertaken.  In  exploring  for  pus  in  deep- 
seated  abscesses  in  the  abdomen  or  pelvis,   care  should  be   exercised   to 


ABSCESS.  253 

insert  the  needle  in  such  a  direction,  whenever  this  is  possible,  as  not  to 
penetrate  the  free  peritoneal  cavity;  whenever  this  cannot  be  done  it 
should  be  introduced  in  such  manner  that,  after  its  removal,  the  puncture 
is  sufficiently  oblique  to  prevent  the  escape  of  pus.  In  such  cases  it  is 
always  advisable  to  combine  aspiration  with  exploration.  If  the  tension 
in  the  abscess  is  diminished  by  removing  a  portion  of  its  contents  extrava- 
sation is  less  likely  to  occur. 

Treatment. — A  correct  diagnosis  made,  the  old  rule  uli  pus  ibi  evacuo 
is  as  applicable  to  the  treatment  of  an  acute  abscess  at  the  present  time 
as  it  was  centuries  ago.     Nothing  is  gained  by  expectant  treatment.     The 
popular  belief  that  an  abscess  should  be  drawn  near  the  surface  by  the 
use  of  filthy  poultices  before  it  should  be  opened  is  fallacious  both  in 
theory  and  practice.     An  abscess  is  ready  to  be  opened  as  soon  as  an  ade- 
quate quantity  of  pus  has  formed  to  constitute  an  abscess  sufiicient  in 
size  to  be  recognized  by  the  surgeon  as  such.     Students  have  generally 
been  taught  that  an  abscess  should  be  evacuated  by  a  free  incision.     This 
advice  dates  back  to  the  time  when  antiseptics  were  not  known  and  tubu- 
lar drainage  had  never  been  heard  of.    The  laying  open  of  an  acute  abscess 
by  an  extensive  incision  is  no  longer  necessary.     The  indications  in  the 
surgical  treatment  of  an  acute  abscess  are  to  open  it  in  such  a  manner  as 
to  secure  perfect  evacuation  and  to  resort  to  such  means  as  will  prevent 
reaccumulation  of  pus.    These  indications  can  be  fulfilled  much  better  by 
making  multiple  small  incisions  and  establishing  free  drainage  by  the  in- 
sertion of  tubular  drains  than  by  making  a  single  long  incision;    at  the 
same  time,  such  treatment  will  leave  the  parts  in  better  condition  for 
rapid  healing  than  by  the  old-fashioned  incisions.     The  incisions  need 
never  be  more  than  an  inch  in  length,  through  which  a  rubber  drainage- 
tube  the  size  of  the  little  finger  can  be  readily  introduced.    Abscesses  up 
to  the  size  of  an  orange  do  not  require  more  than  one  incision.    Abscesses 
larger  than  this  should  be  treated  by  through  drainage  wherever  this  is 
possible.     In  deep-seated  abscesses  the  first  incision  is  made  at  a  point 
where  fluctuation  is  most  distinct,  or  in  the  direction  of  the  track  of  the 
needle  of  the  exploring  syringe,  if  the  pus  has  been  located  by  the  use  of 
this  instrument.    Instead  of  incising  the  abscess  with  one  stroke  of  the 
knife  I  always  incise  the  skin  and  fascia  to  the  extent  of  an  inch,  and  then 
with  a  pair  of  sharp-pointed  hemostatic  forceps  I  tunnel  the  intervening 
tissues.    As  soon  as  the  point  of  the  instrument  has  reached  the  abscess- 
cavity,  pus  will  escape  along  the  side  of  the  instrument;    the  handles  of 
the  forceps  are  now  unlocked  and  the  blades  separated  sufficiently  so  that 
upon  the  withdrawal  of  the  instrument  the  opening  is  enlarged  sufficiently 
to  introduce  a  drainage-tube  of  requisite  diameter.     If  counter-openings 
are  to  be  made,  the  same  forceps  is  carried  across  the  abscess-cavity  and 


254  PRINCIPLES    OF    SUEGEET. 

pushed  from  within  outward  at  a  point  where  drainage  is  most  required, 
the  skin  over  the  point  is  cut  with  a  knife,  the  opening  dilated,  and  a 
drainage-tube  drawn  through.  The  surface  over  the  abscess  and  a  con- 
siderable distance  beyond  it  should  be  shaved  and  disinfected  before  the 
abscess  is  opened.  After  incision  and  drainage  the  abscess-cavity  is 
washed  out  with  a  weak  antiseptic  solution  until  the  fluid  returns  clear, 
when  a  moist,  'hot,  antiseptic  dressing  is  applied.  After  twenty-four  or 
forty-eight  hours  the  dressing  is  removed,  the  drain  shortened,  or,  if 
through  drainage  has  been  made,  the  drain  is  cut  through  in  the  middle 
and  each  opening  is  drained  separately.  If  suppuration  has  not  ceased, 
the  cavity  is  again  irrigated.  It  is  seldom  that  an  abscess-cavity  heals 
without  further  suppuration  after  it  has  been  incised  and  drained,  even 
under  the  strictest  aseptic  precautions.  The  inner  lining  of  the  walls 
of  the  abscess  remains  infected  with  pus-microbes,  and  a  limited  suppura- 
tion, even  in  the  most  favorable  cases,  continues,  at  least  until  after  the 
second  dressing.  The  dressings  should  be  so  applied  as  to  make  equable 
compression,  for  the  purpose  of  keeping  the  surfaces  of  the  abscess-cavity 
in  accurate  apposition.  The  drainage-tubes  are  removed  as  soon  as  sup- 
puration has  ceased,  when  healing  of  the  aseptic  cavity  takes  place  by 
granulation,  in  the  manner  described  in  the  healing  of  wounds.  An  im- 
portant element  in  the  treatment  of  abscesses  is  to  secure  absolute  rest 
for  the  part  affected.  Patients  suffering  from  large  abscesses  should  be 
kept  in  bed,  and  in  the  treatment  of  such  affections  of  one  of  the  extremi- 
ties rest  is  secured  by  the  application  of  a  well-padded  splint,  which  will 
not  only  prove  an  efficient  means  of  mitigating  pain,  but  will  keep  the 
parts  in  a  condition  most  conducive  to  rapid  healing. 

CHEONIC  ABSCESS. 

A  chronic,  congestive,  cold,  or,  as  it  is  sometimes  called,  migrating 
abscess  can  almost  always  be  traced  to  some  specific  chronic  inflammation, 
most  frequently  of  a  tubercular  nature.  What  has  been  called  a  chronic 
abscess  is  very  often  no  abscess  at  all.  In  tubercular  processes  the 
product  of  tissue-proliferation  undergoes  coagulation-necrosis  and  dis- 
integrates into  a  granular  mass,  which,  when  mixed  with  a  sufficient 
quantity  of  serum,  forms  an  emulsion  that  macroscopically  resembles 
pus,  but  under  the  microscope  shows  none  of  the  histological  elements 
which  are  found  in  true  pus.  Am  abscess  can  only  he  called  such  if  it  contain 
pus.  A  true  chronic  abscess  can  originate  in  a  tubercular,  actinomycotic,  or 
syphilitic  lesion  when  the  granulation-tissue  is  secondarily  infected  by  the 
localization  of  pus-microbes,  which  concert  the  embryonal  cells  into  pus- 
corpuscles.  Occasionally  secondary  infection  with  pus-microbes  of  such 
a  granulating  focus  is  followed  by  an  acvite  phlegmonous  inflammation. 


CHRONIC    ABSCESS.  255 

which  extends  rapidly  to  the  surrounding  tissues;  but  usually  the  sup- 
purating process  progresses  slowly,  and  is  not  attended  by  any  of  the 
symptoms  of  acute  inflammation.  What  has  been  described  as  a  cold  abscess 
is  a  cavity  containing  the  debris  of  the  product  of  a  tubercular  inflammation, 
and  is  usually  in  communication  with  the  primary  tubercular  lesion.  Such 
abscesses  frequently  appear  at  a  distance  from  the  primary  seat  of  the  dis- 
ease. Thus  tuberculosis  of  the  vertebrse  gives  rise  to  a  lumbar  abscess  if 
the  swelling  appear  in  the  lumbar  region.  It  is  called  a  psoas  abscess  if 
the  tubercular  product  gravitate  along  the  course  of  the  psoas  muscle  and 
appear  as  an  abscess  underneath  Poupart's  ligament.  Abscesses  origi- 
nating in  the  hip-joint  often  make  their  first  appearance  over  the  outer  or 
inner  aspect  of  the  thigh,  some  distance  below  the  joint.  Abscesses  origi- 
nating in  the  shoulder-joint  often  wander  a  considerable  distance  away 
from  the  joint,  along  the  course  of  the  biceps  or  triceps  muscle. 

Bacteriological  examination  of  the  contents  of  such  abscesses  will  show 
conclusively  whether  they  are  true  pus-containing  abscesses  or  whether  they 
are  pseudo-abscesses.  If  cultivations  are  made  with  their  contents,  pus- 
microbes  will  grow  upon  proper  nutrient  media  if  it  is  a  true  abscess,  while 
from  the  contents  of  a  pseudo-abscess  only  the  microbes  of  the  primary 
infection  can  be  cultivated.  The  information  obtained  by  the  discovery 
of  the  essential  cause  can  be  confirmed  by  inoculation  experiments.  Cold 
abscesses,  as  a  rule,  are  painless,  not  tender  to  the  touch,  and  give  rise  to 
little  or  no  febrile  disturbances. 

Diagnosis.- — The  diagnosis  of  a  chronic  abscess  is  based  not  so  much 
upon  the  location,  size,  and  characteristic  features  of  the  swelling  as  a 
careful  consideration  of  the  symptoms  of  the  local  lesion  from  which  it 
started.  Tubercular  affections  of  the  spine  and  hip-joints  are  accom- 
panied by  such  well-defined  symptoms  at  the  stage  when  abscesses  form 
that  the  primary  lesion  can  be  located  without  much  difficulty.  A  chronic 
paranephric  abscess  often  develops  in  the  course  of  a  tubercular  pyelo- 
nephritis. A  tubercular  pelvic  abscess  is  frequently  associated  with  pri- 
mary tuberculosis  of  the  Fallopian  tube.  A  chronic  abscess  often  arises 
around  a  tubercular  gland  and  appears,  in  consequence  of  infection  with 
pus-microbes,  as  a  chronic  suppurative  perilymphadenitis.  In  such  cases 
the  gland  itself  has  undergone  caseation,  and  is  often  found  extensively 
separated  from  the  surrounding  tissues  by  the  suppurative  process.  In 
reference  to  the  nature  of  the  swelling  and  the  character  of  its  contents, 
an  exploratory  puncture  will  furnish  positive  diagnostic  information. 

Treatment. — The  indications  for  early  surgical  interference  in  the 
treatment  of  chronic  abscess  are  not  so  urgent  as  in  the  acute  variety. 
These  abscesses  appear  months  and  often  years  after  the  commencement 
of  the  primary  disease.    While  an  acute  abscess  should  always  be  opened 


256  PRINCIPLES    OF    SUEGERY. 

under  aseptic  precautions,  it  becomes  a  matter  of  duty  and  conscience  to 
deal  with  a  chronic  abscess  in  a  surgical  way,  only  under  the  strictest  and 
most  elaborate  aseptic  precautions.  It  is  a  well-known  clinical  fact  that 
when  such  an  abscess  opens  spontaneously,  or  is  incised  in  a  careless  way, 
profuse  suppuration  and  hectic  fever  follow,  with  only  too  often  a  speedy 
fatal  result  from  septic  infection.  Additional  infection  with  pus-microbes 
results  in  the  destruction  of  the  granulations  which  line  the  cavity,  and 
the  patient  frequently  dies  from  septic  infection.  Unless  the  surround- 
ings of  the  patient  admit  of  carrying  out  the  aseptic  treatment  to  its 
fullest  and  most  perfect  extent,  a  chronic  abscess  should  not  be  evacuated 
by  incision.  Tubercular  abscess  should  be  treated  by  tapping  and  injec- 
tion of  iodoform-glycerin  emulsion,  as  this  treatment  for  many  years  has 
yielded  most  brilliant  results.  One  great  difficulty  in  evacuating  a  tuber- 
cular abscess  by  aspiration  is  the  blocking  of  the  needle  or  trocar  by  shreds 
of  necrosed  tissue,  which  often  interferes  with  complete  evacuation.  A 
chronic  abscess  should  always  be  treated  by  incision  if  this  treatment  fail, 
if  by  such  procedure  the  primary  lesion  can  be  made  accessible  to  direct 
treatment.  If  such  a  course  is  adopted,  the  incision  is  made  large  enough 
so  that  the  whole  cavity  can  be  thoroughly  scraped  out  and  all  of  the 
infected  tissues  removed.  After  thoroughly  curetting  the  cavity  is 
cleansed  and  disinfected,  and  after  drying  it  is  iodoformized.  The  wound 
is  then  sutured,  drained,  and  treated  on  the  same  principles  as  a  recent 
wound.  The  treatment  of  special  forms  of  chronic  abscess  will  be  con- 
sidered more  in  detail  in  the  chapter  on  "Surgical  Tuberculosis." 

Phlegmonous  Inflammation,  with  Suppuration. — Phlegmonous  inflam- 
mation with  suppuration  is  clinically  characterized  by  rapid  extension 
of  the  disease  without  leading  to  a  circumscribed  collection  of  pus  or 
abscess.  From  the  pus  of  this  form  of  infection  the  streptococcus  can  be 
cultivated  more  frequently  than  the  staphylococcus,  and  in  some  cases 
both  of  these  microbes  are  found  in  the  same  pus.  The  inflammation 
affects  the  connective  tissue,  and  extends  rapidly  along  intermu.scular 
septa,  fascia,  and  tendon-sheaths.  This  form  of  suppurative  inflammation 
is  prone  to  follow  compound  fractures,  railroad  and  other  crushing  in- 
juries, and  all  injuries  attended  by  extensive  contusion  of  connective  tis- 
sue. It  also  frequently  follows  neglected  paronychia,  punctured  and  lacer-'* 
ated  wounds  of  the  fingers  and  hands.  The  first  symptoms  usually  appear 
within  four  days  after  the  injury.  The  general  symptoms  are  ushered  in 
by  a  chill,  followed  by  high  temperature  and  rapid  pulse.  The  first  local 
symptoms  are  a  copious,  sanious  discharge  from  the  Avound  and  a  rapidly- 
spreading  oedema.  The  tissues  are  infiltrated  with  the  same  kind  of  fluid, 
and  if  life  is  prolonged  sufficiently  long  a  difi^use  suppuration  is  inevitable. 
The  symptoms  of  sepsis  in  this  affection  predominate  because  the  pus- 


PHLEGMONOUS    INFLAMMATION,    WITH    SUPPUKATION.  257 

microbes  have  invaded  an  extensive  area  of  tissue,  and  are  reproduced  with 
great  rapidity  and  gain  entrance  into  the  general  circulation  at  an  early 
stage;  at  the  same  time  the  necrosed  tissues,  saturated  with  the  bloody 
serum,  furnish  a  good  soil  for  the  growth  of  putrefactive  bacteria.  In 
most  of  these  cases  the  septic  cellulitis  is  accompanied  by  lymphangitis, 
the  parts  presenting  an  erysipelatous  appearance. 

Treatment. — Phlegmonous  inflammation  of  the  type  just  described 
calls  for  early  and  energetic  treatment  before  suppuration  has  appeared. 
The  pus-microbes  are  present  in  such  quantities  that  the  connective  tissue, 
partially  devitalized  by  an  injury,  becomes  necrosed  from  the  local  toxic 
action  of  the  toxins  of  the  pus-microbes.  To  render  such  wounds  aseptic 
is  one  of  the  most  difficult  tasks  in  surgery.  Small  incisions  and  drainage 
will  not  accomplish  the  desired  object.  The  infected  tissues  must  be  freely 
exposed  by  as  many  incisions  as  may  be  required.  The  secondary  disinfec- 
tion in  such  a  case  must  be  regarded  in  the  light  of  a  capital  operation. 
The  patient  should  be  placed  under  the  influence  of  an  ansesthetic,  the 
limb  shaved  and  disinfected,  and  by  large  incisions  the  infected  tissues 
must  be  rendered  accessible  to  direct  means  of  disinfection.  Before  oper- 
ating, the  limb  should  be  rendered  bloodless  by  Esmarch's  constrictor. 

In  compound  fractures  the  tissues  immediately  over  the  fragments 
should  be  incised  sufficiently  so  that  the  fractured  ends  can  be  turned 
out.  The  infected  medullary  tissue  should  be  scooped  out  with  a  sharp 
spoon,  and  all  clots  and  necrosed  tissue  removed;  the  parts  are  then 
thoroughly  irrigated  with  corrosive  sublimate  (1  to  1000),  or  carbolic  acid 
(1  to  20),  after  which  the  whole  surface  is  dried  and  brushed  over  with  a 
10-per-cent.  solution  of  chloride  of  zinc.  Pockets  and  sinuses  which 
cannot  be  reached  with  the  sharp  spoon  can  be  rendered  aseptic  by  pour- 
ing in  peroxide  of  hydrogen,  which,  in  such  cases,  is  a  remedy  of  great 
value.  The  bones  are  then  placed  in  proper  position,  a  number  of  counter- 
openings  made,  and  a  sufficient  number  of  tubular  drains  introduced; 
after  which  a  copious  antiseptic  dressing  is  applied  and  the  limb  properly 
immobilized,  great  care  being  taken  to  prevent  decubitus  or  gangrene  from 
pressure  by  protecting  the  parts  exposed  to  pressure  with  sterile  or  salic- 
ylated  cotton. 

During  the  subsequent  treatment  such  a  limb  should  be  slightly  ele- 
vated and  suspended.  If  after  this  treatment  the  temperature  is  not  low- 
ered within  six  hours  and  the  remaining  symptoms  are  not  improved, 
it  is  evident  that  the  secondary  disinfection  has  not  succeeded  in  obtain- 
ing an  aseptic  condition  of  the  wound.  If  amputation  does  not  appear 
to  be  indicated  at  this  time,  another  effort  should  be  made  to  secure  asep- 
ticity  by  resorting  to  permanent  irrigation.  The  antiseptic  dressing  is  re- 
moved and  not  reapplied.    The  parts  are  covered  with  a  compress  wrung 


258 


PEIXCIPLES    OF    SUEGERY. 


out  of  a  ^/o-per-cent.  solution  of  acetate  of  aluminum,  and  constant  irri- 
gation made  with  the  same  solution.  The  simplest  arrangement  for  con- 
stant irrigation  is  a  reservoir  holding  the  warm  solution  suspended  over 
the  patient's  bed,  and  connected  with  the  principal  drainage-tube  by 
means  of  a  rubber  tubing  and  a  glass  tip,  In  large,  open,  suppurating 
wounds  and  compound  fractures  the  apparatus  shown  in  Fig.  104  can  be 
used  to  advantage.  By  siphon-action  the  fluid  is  conducted  from  the  ves- 
sel to  every  part  of  the  wound.  The  amount  of  fluid  flowing  through  the 
tube  can  be  regulated  by  compressing  the  tube  to  the  desired  extent  with 
a  clothes-pin.    The  limb  being  suspended,  the  fluid  is  conducted  away  from 


Pig.  104.— Irrigating  Apparatus. 


it  into  a  vessel  by  means  of  a  sheet  of  rubber  cloth,  mackintosh,  or  gutta- 
percha. 

Constant  irrigation  with  a  harmless,  non-toxic,  yet  efficient  antiseptic 
solution  in  these  cases  is  of  the  greatest  value,  as  the  wound-secretion 
is  constantly  washed  away,  and,  as  no  accumulation  can  take  place,  the 
danger  of  sepsis  from  products  of  putrefaction  is  greatly  diminished;  at 
the  same  time,  the  tissues  are  kept  constantly  saturated  with  the  solution, 
which  at  least  will  exert  a  potent  inhibitory  influence  upon  the  action  and 
multiplication  of  pus-microbes  in  the  living  tissues.  Should  a  faithful 
attempt  at  obtaining  an  aseptic  condition  by  this  method  of  treatment 


PEOGEESSIVE   PUEULENT    INFILTEATION.  259 

prove 'inefficient  after  a  fair  trial^  the  question  of  sacrificing  a  limb,  to 
save,  if  possible,  a  life,  will  present  itself. 

Helferich  has  abandoned  small  incisions  and  drainage-tubes  in  the 
treatment  of  extensive  phlegmonous  inflammation  and  has  substituted  for 
them  laying  open  of  the  entire  field  of  inflammation  by  an  incision  from 
one  end  to  the  other,  and  after  thorough  disinfection  packs  the  cavity  with 
aseptic  gauze  saturated  with  a  solution  of  boric  and  salicylic  acid  or  acetate 
of  aluminum. 

In  the  absence  of  recognizable  secondary  foci  in  distant  organs,  the 
surgeon  will  not  be  able  to  ascertain  whether  a  fatal  form  of  general  in- 
fection exists  in  a  special  case,  and  it  is  therefore  always  justifiable  to 
resort  to  a  mutilating  operation  as  a  last  resort,  provided  the  patient's 
strength  warrants  such  a  procedure.  As  in  cases  of  progressive  gangrene, 
so  in  cases  of  progressive  phlegmonous  inflammation,  it  is  exceedingly 
difficult  to  decide  upon  the  exact  location  where  the  amputation  should  be 
made,  as  a  distinct  line  of  demarcation  between  healthy  and  infected 
tissues  is  never  present.  The  only  rule  to  go  by  in  the  selection  of  the 
site  of  amputation  is  to  secure  healthy  skin-flaps  and  to  make  the  circular 
section  of  the  muscular  tissue  above  the"  tissues  presenting  macroscopical 
evidences  of  infection.  The  condition  of  the  deep  connective  tissue  fur- 
nishes important  information  concerning  this  question.  The  infection  is 
sure  to  extend  as  far  as  any  undermining  or  sloughing  of  connective 
tissue  has  taken  place;  hence,  amputation  should  be  done  above  these 
limits.  The  general  treatment  of  phlegmonous  inflammation  is  considered 
upon  the  same  principles  as  the  treatment  of  sepsis  from  other  causes. 

PEOGEESSIVE    PUEULENT   INFILTEATIOlSr. 

This  is  the  purulent  oedema  of  Pirogoff.  It  is  a  more  advanced 
stage  of  what  has  just  been  described  as  progressive  phlegmonous  inflam- 
mation with  suppuration.  Purulent  infiltration  follows  upon  the  heels  of 
phlegmonous  inflammation,  and  is,  consequently,  clinically  also  noted  for 
its  progressive  character.  The  infiltration  is  often  very  extensive,  involv- 
ing, in  many  cases,  an  entire  extremity.  It  is  always  attended  by  very 
extensive  connective-tissue  necrosis.  The  pus  burrows  deeply  among  the 
muscles,  and  detaches  the  skin  over  a  large  surface.  The  external  ap- 
pearances seldom  indicate  the  extent  of  the  disease.  If  the  skin  is  in- 
cised freely,  the  parts  beneath — the  muscles,  vessels,  and  nerves — appear 
as  plainly  as  in  a  dissection  made  to  show  the  anatomical  relations  of 
these  parts.  Purulent  infiltration  following  progressive  phlegmonous  in- 
flammation has  often  been  mistaken  for  erysipelas,  and  has  been  called 
phlegmonous  erysipelas.  If  purulent  infiltration  complicate  erysipelas,  it 
occurs  in  consequence  -of  secondary  infection  with  pus-microdes,  and  not  as 


260  PEINCIPLES    OF    SUEGEKY, 

a  result  of  the  action  of  the  streptococcus  of  erysipelas.  The  gravity  of  this 
disease  depends  largely  upon  the  extent  of  the  tissues  involved.  If  it 
affect  an  entire  limb  the  danger  to  life  is  great.  Death  may  occur  from 
pyemia  or  exhaustion. 

Treatment. — The  surgical  treatment  is  the  same  as  in  abscess,  only 
that  the  incisions  should  be  made  longer,  two  or  three  inches  in  length, 
in  order  to  enable  the  operator  to  remove  the  necrosed  connective  tissue 
and  to  insert  large  tubular  drains.  After  the  first  incision  is  made  a  long, 
curved,  Pean  forceps  is  introduced,  the  cavity  explored,  and  counter-open- 
ings made  upon  the  point  of  the  instrument  in  places  where  counter-drain- 
age will  be  most  effective.  The  cavity  must  be  drained  at  different  points 
from  one  end  to  the  other.  If  the  forceps  is  not  long  enough  to  reach 
both  extremities  it  is  removed  and  inserted  again  into  the  second  opening, 
and  so  on  until  the  cavity  is  thoroughly  drained.  It  is  advisable  to  bring 
each  drainage-tube  out  of  two  openings  and  secure  each  end  with  a  safety- 
pin.  In  cases  of  purulent  infiltration  of  an  entire  lower  extremity  I  have 
often  made  as  many  as  twelve  incisions  and  inserted  half  as  many  drain- 
age-tubes. After  the  cavity  has  been  thoroughly  drained,  it  is  washed  out 
with  one  of  the  milder  antiseptic  solutions.  An  excellent  solution  for  this 
purpose  is  iodinized  water.  This  can  be  readily  prepared  by  adding  tincture 
of  iodine  to  sterilized  water  until  the  solution  has  the  color  of  sherry-wine. 
A  solution  of  this  strength  is  a  valuable  antiseptic,  and  can  be  used  re- 
peatedly and  in  large  quantities  without  fear  of  causing  intoxication.  I  have 
never  succeeded  in  rendering  such  a  large  suppurative  cavity  aseptic  with 
one  irrigation,  and  have  consequently  abandoned  the  occlusive  antiseptic 
dressings  in  these  cases.  It  is  much  better  to  apply  a  compress  wrung  out 
of  warm  salicylated  water  or  a  1-per-cent.  solution  of  acetate  of  aluminum, 
which  can  be  removed  and  reapplied  every  time  the  cavity  is  irrigated, 
which  at  first  should  be  done  every  four  to  six  hours.  The  warmth  and 
moisture  of  the  compress  can  be  maintained  by  covering  it  with  gutta- 
percha tissue  or  mackintosh  cloth.  As  burrowing  of  pus  often  does  not 
stop  even  after  efficient  drainage  has  been  established,  the  case  should 
be  watched  with  great  care,  and  any  attempt  at  burrowing  should  be 
promptly  met  by  free  incision  and  additional  provision  for  drainage.  It 
is  always  advisable  to  siipport  the  limb  in  proper  position  upon  some 
kind  of  a  suspension  splint,  both  for  the  purpose  of  securing  rest  and  to 
prevent  contractures.  As  soon  as  suppuration  has  nearly  ceased  the  drains 
are  shortened  and  irrigations  made  less  frequently.  It  is  a  consolation  to 
know  that  such  patients,  especially  if  they  are  not  advanced  in  years,  and 
are  free  from  any  other  disease,  often  rally  and  make  an  excellent  recovery 
after  their  strength  has  been  reduced  to  a  dangerous  extent  and  their 
bodies  reduced  to  a  skeleton  by  the  prolonged  suppuration  and  septic  fever. 


SUPPURATIVE    TENDO-VAGINITIS.  361 

If  suppuration  is  not  controlled  by  drainage  and  antiseptic  irrigation,  and 
especially  if  the  temperature  and  pulse  indicate  a  continuance  of  absorp- 
tion of  septic  material,  continuous  antiseptic  irrigation  should  be  insti- 
tuted, and,  if  this  fail,  amputation  may  become  an  unavoidable  necessity. 
If  amputation  is  decided  upon  the  deep  incision  must  be  made  beyond  the 
limits  of  the  suppurating  area.  If  the  suppuration  has  extended  as  far 
as  the  hip-joint  it  may  become  necessary  to  utilize  for  flaps  the  skin  which 
has  been  undermined,  in  order  to  secure  a  covering  for  the  stump.  If  such 
a  procedure  become  necessary  the  internal  surface  of  the  skin-flaps  must 
be  rendered  aseptic  by  using  the  sharp  spoon  and  scissors  in  freeing  it  from 
infected  tissue.  During  the  whole  course  of  the  disease,  which  gives  rise 
to  purulent  infiltration,  the  jDatient's  strength  must  be  supported  by  stimu- 
lants and  tonics  and  a  concentrated  nutritious  diet. 

SUPPUEATIVE    TENDO-VAGINITIS. 

Another  form  of  rapidly-spreading  inflammation  is  suppurative  tendo- 
vaginitis. As  the  name  implies,  it  is  an  acute  inflammation  of  tendon- 
sheaths  terminating  in  suppuration.  It  occurs  most  frequently  in  the 
tendon-sheaths  of  the  fingers,  hand,  and  forearm.  It  develops  usually 
from  an  infected  wound  of  the  finger  or  hand,  or  as  a  complication  in 
the  different  forms  of  paronychia.  The  inflammation  travels  along  the 
course  of  the  tendon,  starting,  perhaps,  from  one  of  the  tendons  of  a 
finger,  extends  to  the  palm  of  the  hand,  underneath  the  annular  liga- 
ment to  the  flexor  muscles  of  the  forearm,  where  it  often  produces  a 
phlegmonous  inflammation  which,  in  the  course  of  time,  may  involve 
the  whole  forearm.  The  tendons  are  often  destroyed,  and  can  be  pulled 
out  after  a  few  weeks, — an  occurrence  which  is  always  followed  by  perma- 
nent functional  impairment  of  the  affected  finger  or  of  the  whole 
hand.  Not  infrequently  suppurative  inflammation  of  a  tendon-sheath 
extends  to  one  or  more  joints  over  which  the  tendon  passes,  causing 
a  complication,  which  often  necessitates  amputation.  This  affection  is 
always  attended  by  severe  pain,  and,  if  extensive,  by  grave  constitutional 
disturbances.  The  extent  of  the  disease  can  be  ascertained,  approximately, 
at  least,  by  the  length  of  the  external  swelling,  and  especially  by  the  ten- 
derness along  the  course  of  the  tendon.  Frequently  the  inflammation  at- 
tacks adjacent  tendon-sheaths  and  the  pus  undermines  the  entire  palmar 
fascia. 

Treatment.  —  The  surgical  treatment  of  suppurative  tendo-vaginitis 
must  be  thorough  if  it  shall  be  efficient.  If  it  follow  in  the  course  of  a 
wound,  the  tendon  in  the  wound  is  exposed;  if  it  develop  during  an  attack 
of  paronychia,  it  is  laid  bare  by  a  free  incision.  Along  the  course  of  the 
tendon  a  curved  forceps  is  passed  to  the  upper  limits  of  the  infected  part 


263  PEINCIPLES    OF    SUKGERY. 

of  the  tendon-sheatli,  another  incision  is  made  down  upon  the  point  of 
the  instrument,  and  a  drainage-tube  is  drawn  through.  If  the  end  of  the 
suppurating  cavity  has  not  been  reached  the  forceps  is  again  introduced 
through  the  second  incision  down  to  the  tendon,  a  third  incision  made 
higher  up,  and  another  drainage-tube  drawn  through.  These  manoeuvres 
are  repeated  until  the  upper  extremity  of  the  suppurating  cavity  is 
reached.  Taking  it  for  granted  that  the  suppurative  tendo-vaginitis  com- 
menced in  the  distal  portion  of  the  middle  finger,  and  has  reached  as  far 
as  the  muscles  of  the  forearm,  the  first  drain  should  reach  as  far  as  the 
metacarpo-phalangeal  joint,  the  second  from  here  to  the  middle  of  the 
palm  of  the  hand,  the  third  from  here  to  above  the  annular  ligament,  and 
the  fourth  as  far  as  the  middle  of  the  forearm,  and  if  suppuration  has  ex- 
tended further  it  Avill  become  necessary  to  extend  drainage  higher  up  by 
another  drain.  If  the  whole  palmar  fascia  is  undermined,  a  drain  should 
be  placed  transversely  across  the  hand.  If  the  suppuration  has  extended 
to  adjacent  tendon-sheaths,  more  extensive  provision  for  drainage  will  be 
required.  The  subsequent  treatment  is  the  same  as  in  cases  of  purulent 
infiltration.  Necrosed  tendons  separate  very  slowly,  but  it  is  better  to 
leave  their  elimination  to  the  graimlating  process,  as  it  is  difficult  to  de- 
cide how  much  of  the  tendon  should  be  removed,  and  its  operative  re- 
moval would  often  require  large  incisions,  which  would  heal  at  best  only 
slowly,  and  the  large  cicatrix  would  only  add  to  the  functional,  impair- 
ment of  the  member.  From  time  to  time  traction  can  be  made  upon  the 
tendon  where  it  is  exposed,  so  as  to  remove  it  as  soon  as  it  has  become 
partially  or  completely  detached.  Passive  motion  and  massage  must  be 
instituted  as  soon  as  the  abscess  has  healed,  so  as  to  restore  the  function 
of  the  limb  as  far  as  is  compatible  with  the  existing  condition,  as  not  only 
the  affected  finger,  but  the  whole  hand,  often  will  be  found  to  have  suf- 
fered seriously  from  the  attack.  If  one  of  the  principal  tendons  of  a  finger 
has  sloughed  and  motion  cannot  be  restored,  it  is  advisable  to  immobilize 
the  finger  in  a  slightly-flexed  position,  as  a  curved  finger  is  more  service- 
able than  a  straight  one.  Suppurative  arthritis  occurring  in  the  course 
of  an  attack  of  tendo-vaginitis  often  necessitates  amputation,  more  espe- 
cially if  it  involve  more  than  one  joint  of  a  finger. 

PAEONYCHIA. 

Paronychia,  felon,  whitlow,  are  terms  used  to  designate  an  abscess 
of  a  finger.  All  these  terms  should  be  abolished,  and  abscesses  of  the 
finger,  like  of  other  parts,  should  be  called  in  accordance  with  the  primary 
disease  which  caused  them.  Hueter  made  a  classification  upon  a  strictly 
anatomo-pathological  basis.  The  abscess  may  be  located  in  the  skin, 
and  is  then  a  furuncle;    it  may  involve  the  connective  tissue,  and  is  then 


PAEONYCIilA.  263 

the  product  of  a  phlegmonous  inflammation;  it  may  form  after  an 
attack  of  periostitis  or  osteomyelitis,  or,  finally,  it  may  commence  in  a 
joint,  and  is  then  from  the  beginning  a  suppurative  arthritis.  A  sup- 
purative tendo-vaginitis,  as  a  primary  afEection  of  a  tendon-sheath,  has 
often  been  mistaken  for  an  ordinary  felon,  and  treated  as  such,  with  most 
disastrous  results.  Suppurative  tendo-vaginitis  is  frequently  met  with 
as  a  secondary  affection  of  the  different  pathological  conditions  which 
give  rise  to  abscess  of  the  fingers.  All  of  the  conditions  which  have  been 
enumerated  as  causes  of  abscess  of  the  fingers  are  attended  by  excruciating 
pain,  as  the  anatomical  conditions  necessary  for  the  production  of  this 
symptom- — ^tension  and  abundant  supply  of  sensitive  nerves — are  preemi- 
nent in  inflammatory  affections  of  the  fingers.  The  pain  is  of  a  throbbing 
character,  and  is  always  aggravated  by  placing  the  hand  in  a  dependent 
position,  as  the  venous  congestion  produced  by  this  position  increases  the 
swelling,  and  consequently  the  tension,  in  the  inflamed  part. 

Treatment. — Volumes  have  been  written  on  the  abortive  treatment 
of  paronychia:  the  surest  indication  that  none  of  the  various  means  sug- 
gested have  proved  successful.  Abscesses  of  the  fingers,  as  in  any  other 
part  of  the  body,  result  only  from  infection  with  pus-microbes;  hence, 
any  measure  which  falls  short  of  effecting  complete  sterilization  at  the 
primary  focus  of  infection  must  necessarily  fail  in  accomplishing  the  de- 
sired object.  The  only  rational  treatment  consists  in  the  employment 
of  such  measures  as  will  limit  the  extension  of  the  suppuration.  One  of 
the  most  important  elements  in  the  early  treatment  of  a  felon  is  to  di- 
minish the  blood-supply  to  the  inflamed  part  by  placing  the  limb  in  an 
elevated  position,  and  by  the  continued  application  of  cold.  The  use  of 
ice  in  such  a  superficial  inflammation  will  not  only  tend  to  diminish  the 
congestion,  but  at  the  same  time  it  has  a  positive  influence  in  retarding 
the  reproduction  in  the  tissues  of  the  primary  cause:  the  pus-microbes. 
Poultices  should  never  be  employed.  If  position  and  the  use  of  cold  do 
not  afford  relief,  moist,  hot,  antiseptic  compresses  should  be  applied.  As 
soon  as  pus  has  formed  it  must  be  liberated  by  incision.  The  centre  of 
the  inflammatory  focus  is  accurately  located  by  marking  out  by  pressure 
the  area  of  tenderness,  and  the  incision  is  made  at  this  point  parallel  to 
the  long  axis  of  the  finger.  Scrupulous  care  must  be  exercised  in  render- 
ing the  whole  surface  of  the  finger  aseptic  before  the  incision  is  made. 
It  is  not  good  practice  to  make  the  incision  invariably  down  to  the  bone, 
as  the  inflammation  may  not  extend  to  this  depth.  The  incision  is  only 
carried  down  to,  but  not  beyond,  the  suppurating  focus;  hence,  it  is  made 
down  to  the  bone  only  if  the  abscess  has  originated  in  a  joint  or  has 
followed  an  osteomyelitis  or  periostitis  of  a  phalanx.  As  the  wound  gapes 
freely,  drainage  is  not  required.    The  abscess  is  washed  out  with  an  anti- 


264  PEINCIPLES    OF    SUEGEEY. 

septic  solution  and  the  finger  dressed  antiseptically.  Suppurative  arthritis 
is  treated  by  through  drainage.  In  osteomyelitis  followed  by  necrosis  the 
sequestrum  is  allowed  to  separate  and  is  then  extracted,  which  can  usually 
be  done  after  three  or  -four  weeks.  Excellent  results  are  obtained  after 
the  loss  of  a  complete  phalanx,  as  the  bone  is  often  reproduced  almost  to 
perfection  by  the  periosteal  sheath.  Amputation  only  becomes  necessary 
in  cases  of  osteomyelitis  affecting  more  than  one  phalanx,  complicated  by 
suppurative  arthritis  of  the  adjacent  joints. 

SUPPUEATIVE    FOLLICULITIS. 

Suppurative  folliculitis  is  a  very  common  affection  and  represents  an 
abscess  on  the  smallest  scale.  The  outlet  of  the  hair-follicle  is  narrowed 
by  the  acute  inflammation  and  retention  of  the  secretions,  and  suppurative 
inflammation  is  the  result  of  this  stenosis.  The  hair  occupies  the  centre 
of  the  minute  abscess-cavity.  The  disease  appears  clinically  usually  as  a 
multiple  affection  and  is  well  represented  by  sycosis. 

FUEUNCLE. 

A  furuncle  is  a  small  abscess  of  the  skin.  The  centre  of  a  furuncle 
is  always  occupied  by  a  plug  of  necrosed  connective  tissue  vulgarly  called 
a  core.  Longard  has  made  a  careful  microscopico-bacteriological  exami- 
nation of  9  cases  of  furunculosis  in  young  children.  In  4  of  these  cases 
he  found  the  staphylococcus  pyogenes  albus  alone,  in  5  cases  in  com- 
bination with  the  staphylococcus  pyogenes  aureus.  The  identity  of  these 
microbes  with  those  described  by  Rosenbach  was  demonstrated  by  cultiva- 
tion and  experiments  on  rabbits.  The  microbes  were  not  found  in  the 
faecal  discharges  of  the  patients,  but  were  discovered,  in  small  numbers, 
in  the  diapers  of  healthy,  unclean  children,  as  well  as  in  the  diapers  of 
those  suffering  from  suppurative  folliculitis.  He  believes  that  the  pus- 
microbes  are  the  direct  and  sole  cause  of  the  affection,  and  that  infection 
takes  place  through  the  sweat-glands,  as  the  microbes  were  found  in 
abundance  upon  the  inner  surface  of  the  membrana  propria  of  these 
glands.  As  soon  as  the  microbes  reach  the  subcutaneous  connective  tissue 
they  produce  suppurative  inflammation.  Experiments  on  dogs  and  rab- 
bits, by  cutaneous  inoculations  with  pus-microbes  cultivated  from  the 
furuncles,  produced  a  slight  swelling  and  redness,  and,  in  some  instances, 
the  formation  of  small  pustules.  The  result  of  these  inoculations  was 
always  the  same,  whether  the  cultures  were  made  from  the  pus  of  a 
furuncle,  a  suppurating  wound  that  healed  without  fever,  or  from  a  pyse- 
mic   patient.      The   inoculation   experiments   of   Garre,   Bockhardt,   and 


CAEBUNOLE.  265 

Bumm,  upon  themselves,  have  been  previously  referred  to,  and  they  prove 
that  many  of  the  circumscribed  suppurative  affections  of  the  skin  (among 
them  furuncle)  are  caused  by  the  direct  inoculation  with  pus-microbes, 
which  enter  the  connective  tissue  either  through  a  slight  abrasion  or 
through  the  glands  of  the  skin.  Furuncles  often  appear  multiple,  either 
in  the  same  region  or  widely  separated  from  each  other  over  different  parts 
of  the  body.  In  such  cases  the  successive  appearance  of  furuncles  would 
tend  to  prove  the  reproduction  and  diffusion  of  the  primary  ca^ise,  the  pus- 
microbes,  over  the  surface  of  the  body. 

Treatment.- — The  prophylactic  treatment  consists  in  securing  for  the 
skin  a  healthy  condition.  By  the  free  use  of  hot  water  and  potash-soap 
the  openings  of  the  glands  of  the  skin  are  cleared  of  accumulation  of 
pus-microbes  and  of  materials  which  might  serve  as  culture  substances. 
After  thorough  cleansing  of  the  skin  the  surface  should  be  washed  either 
with  absolute  alcohol  or  a  50-per-cent.  solution.  In  patients  suffering 
from  furuncle,  the  slightest  abrasions  should  be  treated  with  care,  in 
order  to  guard  against  infection.  If  the  general  health  has  been  impaired, 
dietetic  and  medical  treatment  should  be  instituted  to  correct  the  faulty 
nutrition.  We  have  no  special  internal  remedies  to  correct  a  supposed 
suppurative  diathesis  which  does  not  exist.  Sulphide  of  calcium,  which 
has  been  recommended  in  such  strong  terms,  has  no  influence  either  in  the 
prevention  or  cure  of  furuncles.  With  the  first  appearance  of  a  furuncle, 
the  skin  over  and  considerably  beyond  it  should  be  disinfected,  and  a  com- 
press saturated  with  a  weak  antiseptic  solution  applied.  As  soon  as  pus 
appears  it  is  evacuated  through  a  small  incision,  and  if  the  necrosed  tissue 
in  its  centre  has  become  detached  it  is  extracted.  The  interior  of  the 
small  abscess  is  then  disinfected  and  a  small  antiseptic  dressing  applied. 
A  furuncle  is  an  insignificant  lesion,  but  its  proper  treatment  should 
not  be  neglected,  as  numerous  cases  have  been  reported  where  thrombo- 
phlebitis, pyaemia,  and  acute  suppurative  osteomyelitis  could  be  traced  to 
infection  from  aj  furuncle. 

CARBUNCLE. 

A  great  deal  of  confusion  has  been  created  in  the  minds  of  students 
in  reference  to  what  is  really  meant  by  a  carbuncle.  This  confusion  has 
been  brought  about  by  the  teachings  of  some  of  our  text-books,  both  old 
and  recent,  which  assert  that  carbuncle  is  always  caused  by  infection 
with  the  bacillus  of  anthrax,  while  others  speak  of  a  less  malignant 
form  of  carbuncle  caused  by  suppurative  infiammation.  Malignant  car- 
buncle, or  malignant  pustule,  is  the  anthracic  form  of  carbuncle,  which 
always  starts  from  a  single  centre  of  infection,  and  is  always  attended  by 
necrosis  of  the  overlying  skin.     The  ordinary  carbuncle,  which  is  under 


266  PEINCIPLES    OF    SUEGEEY. 

consideration  now,  is  caused  by  infection  with  pns-microbes,  and  difEers 
from  a  fnruncle  only  in  so  far  that  it  is  made  np  of  a  number  of  foci 
of  suppuration,  which  develop  simultaneously  or  in  rapid  succession, 
and  usually  become  confluent.  A  carbuncle  of  this  kind  is  in  reality 
nothing  else,  etiologically  and  pathologically,  but  a  group  of  furuncles.  A 
section  through  a  carbuncle,  before  extensive  liquefaction  has  occurred, 
will  show  a  number  of  foci  of  suppuration  and  necrosis,  each  one  of  which, 
taken  separately,  would  represent  a  furuncle.  On  account  of  the  more 
extensive  area  of  infection  in  carbuncle  than  in  furuncle,  the  local  symp- 
toms are  much  more  severe.  The  tissues  at  an  early  stage  become  so  ex- 
tensively infiltrated  that  the  carbuncle  feels  as  hard  as  cartilage.  The 
pain,  as  a  rule,  is  very  great.  In  size,  a  carbuncle  varies  greatly;  it  is 
sometimes  not  larger  than  a  25-cent  piece,  and  it  may  attain  a  circum- 
ference fully  as  large  as  an  ordinary  soup-plate.  The  inflammation,  which 
first  attacks  the  skin  and  subcutaneous  tissue,  in  unfavorable  cases  ex- 
tends to  the  deeper  tissues  and  also  travels  in  a  peripheral  direction.  If 
the  carbuncle  is  large,  the  skin  covering  it  becomes  gangrenous  and  ex- 
tensive sloughing  takes  place.  If  the  carbuncle  is  small,  composed  of  only 
three  or  four  centres  of  suppuration,  the  skin  is  not  destroyed,  with  the 
exception,  perhaps,  of  a  very  small  portion,  corresponding  to  the  apex  of 
each  furuncular  focus.  Central  necrosis  of  the  connective  tissue  in  each 
suppurating  focus  invariably  occurs,  and,  if  the  inflammation  is  very  se- 
vere and  extensive,  the  whole  carbuncle  becomes  a  necrotic  mass.  In  mild 
cases  the  tissues  between  the  suppurating  foci  are  preserved,  and,  after 
the  elimination  of  the  necrosed  tissue,  the  part  presents  a  cribriform  ap- 
pearance, each  depression  indicating  the  exact  position  of  the  former  focus 
of  infection.  Carbuncle  is  met  with  more  frequently  in  persons  advanced 
in  years  and  in  diabetic  patients,  and  attacks  in  preference  such  parts  as 
are  most  exposed  to  infection  from  without,  as  the  neck,  face,  and  hands. 
The  danger  to  life  connected  with  carbuncle  consists  in  exhaustion  and 
septicEemia,  in  the  progressive  form,  while  thrombophlebitis  and  pygemia 
may  occur  as  fatal  complications,  even  if  the  disease  is  circumscribed  and 
the  local  symptoms  are  not  severe. 

Diagnosis. — The  difl:erential  diagnosis  consists  in  separating  car- 
buncle from  furuncle  and  malignant  pustule,  or  anthracic  pustule.  A 
furuncle  presents  only  one  centre  of  suppuration,  is  more  circumscribed, 
more  superficial,  and  not  attended  by  such'  marked  infiltration  as  car- 
buncle. Malignant  pustule  is  primarily  not  a  suppurative  lesion,  as  it  is 
caused  by  infection  with  the  bacillus  of  anthrax,  and  develops  from  one 
point  of  infection  and  gives  rise  to  necrosis  of  the  skin  at  an  early  stage. 
Carbuncle  starts,  simultaneously  or  in  rapid  succession,  from  three  to  a 
dozen  or  more  suppurating  foci,  is  attended  by  a  hard  induration  of  the 


CAKBUNCLE.  267 

siirroundiiig  connectiYe  tissue,  and  gives  rise  always  to  multiple  foci  of 
necrosis  of  the  subcutaneous  connective  tissue. 

Treatment.  —  The  different  methods,  advised,  at  various  times,  to 
abort  a  carbuncle  have  not  ^Droved  more  successful  than  the  means  sug- 
gested to  check  the  growth  of  a  furuncle.  Very  recently  Beauquinque  has 
made  the  assertion  that  a  carbuncle  can  be  aborted  by  applying  to  the  part 
antiseptics  dissolved  in  alcohol.  He  claims  to  have  succeeded  in  three 
cases  by  applying  tincture  of  iodine.  While  we  have  no  right  to  question 
the  correctness  of  his  diagnosis  or  the  truth  of  his  assertions,  it  is  well 
known  that  the  same  treatment  has  not  been  attended  by  the  same  satis- 
factory results  in  the  hands  of  other  surgeons.  It  is  difficult  to  conceive 
how  the  external  application  of  the  tincture  of  iodine  or  any  other  anti- 
septic alcoholic  solution'  should  have  the  power  to  destroy  the  pus- 
microbes  or  prevent  their  reproduction  when  so  deeply  buried  in  the  tis- 
sues. The  most  potent  agent  to  limit  the  extension  of  the  inflammation 
is  the  continued  application  of  ice.  As  soon  as  pus  has  formed,  the 
different  foci  of  s^ippuration  should  be  exposed  to  direct  means  of  disin- 
fection by  incising  the  carbuncle  under  strict  antiseptic  precautions.  If 
the  carbuncle  is  too  large  for  excision  the  old-fashioned  crucial  incision 
answers  an  excellent  purpose  in  exposing  the  infected  tissues  to  disinfec- 
tion. The  necrosed  and  infected  tissues  are  removed  with  a  sharp  spoon, 
and  the  surface  is  disinfected  by  irrigation  with  a  solution  of  carbolic  acid 
or  corrosive  sublimate;  after  which  the  scraped  surface  is  dried  and 
touched  with  a  10-per-cent.  solution  of  chloride  of  zinc  and  the  part  cov- 
ered with  an  antiseptic  moist  compress.  If  the  primary  disinfection  does 
not  arrest  further  extension  of  the  disease,  the  whole  surface  should  be 
deeply  cauterized  with  the  knife-point  of  Paquelin's  cautery.  After  cauter- 
ization a  compress  saturated  with  a  weak  solution  of  corrosive  sublimate 
is  to  be  applied.  With  the  cessation  of  suppuration  granulations  appear, 
when  the  same  treatment  is  to  be  followed  as  in  the  management  of  granu- 
lating wounds.  Septic  thrombophlebitis  is  announced  by  a  well-marked 
chill,  followed  by  the  usual  grave  symptoms  which  attend  pygemia.  If 
the  thrombosed  vein  can  be  located  in  such  cases  it  should  be  removed 
by  excision,  with  a  faint  hope  that,  by  an  early  recourse  to  this  expedient, 
a  fatal  form  of  pygemia  may  possibly  be  prevented. 

Riedel  has  successfully  resorted  to  excision  of  carbuncle:  a  method 
of  treatment  which  he  strongly  recommends.  A  crucial  incision  is  made 
across  the  carbuncle  and  extending  well  into  the  healthy  tissue.  The  four 
triangular  flaps  are  then  dissected  back  until  healthy  tissue  is  reached,  and 
the  indurated  portion  extirpated.  The  haemorrhage  is  controlled  by  com- 
pression. A  loose  tampon  of  iodoform  gauze  is  then  inserted  in  the  wound, 
the   skin  having  been  brought   back   into   position.      The   wound   heals 


368  PRINCIPLES    OF    SURGERY. 

rapidly,  and  the  loss  of  substance  from  the  centre  will  replace  itself  very 
quickly.  This  operation  greatly  diminishes  the  danger  of  pygemia  and 
shortens  the  duration  of  the  disease. 

In  the  treatment  of  a  carbuncle  amenable  to  excision  owing  to  its 
location  and  size  no  better  treatment  can  be  advised  than  complete  re- 
moval of  every  vestige  of  infected  tissue  with  the  knife.  The  author  cir- 
cumscribes the  infected  territory  by  an  incision  which  penetrates  deep 
enough  to  reach  healthy  tissue,  when  the  whole  mass  is  removed  in  one 
piece.    The  wound  is  covered  by  a  moist  antiseptic  compress. 


CHAPTEK  XI. 

Ulcekation  and  Fistula. 

ULCEE. 

An  ulcer  is  a  defect  of  the  cutaneous  or  mucous  surface,  characterized 
by  an  absence  of  processes  pointing  to  repair  and  an  intrinsic  tendency  to 
peripheral  extension.  The  process  by  which  an  ulcer  is  produced  is  called 
ulceration.  An  ulcer  is  essentially  a  surface  lesion  involving  either  the 
skin  or  any  of  the  mucous  membranes.  The  most  superficial  ulcer  is  one 
in  Avhich  only  the  epithelial  layer  of  the  skin  or  mucous  membrane  is  de- 
stroyed, A  deep  ulcer  is  one  in  which  the  cause  which  produced  the  ulcer 
has  penetrated  the  skin  or  mucous  membrane  and  has  destroyed  the  sub- 
cutaneous or  submucous  tissues  regardless  of  their  anatomical  structure. 
All  ulcers  are  caused  and  are  maintained  by  pathogenic  microbes.  They 
are  the  result  of  a  destructive  inflammation,  and  remain  until  the  primary 
microbic  cause  has  been  removed  or  has  been  rendered  harmless,  when 
ulceration  yields  to  regeneration  and  the  ulcer  is  transformed  into  a  granu- 
lating surface.  The  transition  of  an  ulcer  into  a  healing  surface  takes 
place  as  soon  as  the  embryonal  cells  on  the  surface  of  the  ulcer  retain  their 
vitality  and  are  utilized  in  the  process  of  repair.  At  this,  the  terminal, 
stage  of  ulceration  molecular  destruction  and  suppuration  have  ceased, 
the  granulations  are  firm,  small,  and  very  vascular,  and  at  the  margins 
of  the  granulation  field  a  delicate  blue  line  indicates  the  beginning  of  epi- 
dermization.  It  is  impossible  to  give  a  satisfactory  description  of  an  ulcer 
that  will  apply  to  all  cases,  as  the  appearance  of  the  ulcer  must  necessarily 
vary  according  to  the  location  and  its  size,  the  structure  of  the  tissue  in- 
volved, and  especially  the  nature  of  the  primary  microbic  cause  and  the 
character  of  the  tissue  changes  in  its  immediate  vicinity.  Ulcers  of  the 
mucous  membranes  differ  from  those  of  the  skin,  owing  to  their  being 
constantly,  bathed  with  the  secretions  of  the  affected  organ;  while  the 
products  of  destruction  of  an  ulcer  of  the  skin  frequently  become  inspis- 
sated and  form  a  crust  which  may  be  a  valuable  protection  to  the  ulcer, 
but  which  may  also  become  a  cause  of  retention  of  pus.  An  ulcer  is 
superficial  or  deep  according  to  the  depth  to  which  the  microbic  cause  has 
penetrated  and  destroyed  the  tissues.  The  size  of  the  ulcer  is  also  a  sure 
indication  of  the  extent  of  infection  of  the  affected  surface.  Eesistance 
to  ulceration  is  not  shared  alike  by  all  the  tissues.  The  connective  tissue 
readily  yields  to  the  microbic  causes  which  produce  ulceration,  while 

(369) 


270  PEINCIPLE&    OF    SUEGEKY. 

muscles,  bone^,  cartilage,  and  especially  blood-vessels  offer  greater  resist- 
ance. The  microbes  constantly  found  upon  the  surface  and  the  tissues 
of  an  ulcer,  irrespective  of  the  primary  cause,  are  the  pus-microbes.  Every 
ulcer  represents  an  open,  suppurating  inflammation.  In  tuberculosis, 
gmnma,  lepra,  and  actinomycosis  of  any  of  the  surfaces  mixed  infection 
with  pus-microbes  invariably  takes  place  as  soon  as  a  surface  defect  has 
occurred,  and  the  suppurative  lesion  which  follows  as  the  result  of  the 
mixed  infection  always  greatly  modifies  and  frequently  overshadows  the 
primary  infection.  The  exposure  of  tumor-tissue  to  external  infection  is 
followed  by  a  similar  complication.  Vascular  disturbances,  such  as  are 
caused  by  atheroma  of  the  arteries  and  varicose  veins,  are  not  only  frequent 
and  potent  causes  in  the  production  of  ulceration,  but  exert  at  the  same  time 
a  very  deleterious  influence  upon  the  nutrition  of  the  tissues  in  the  immedi- 
ate vicinity  of  the  ulcer.  In  the  description  of  an  ulcer  special  attention  is 
given  to  its  floor  and  margins.  The  floor  of  every  ulcer  is  covered  by 
what  are  generally  called  "unhealthy  granulations."  The  granulations 
are  either  scanty  or  very  abimdant;  in  the  latter  case  they  are  said  to  be 
fungous.  They  are  flabby,  often  pale  and  oedematous,  and  exhibit  the  de- 
structive effect  of  the  pus-microbes  and  their  toxins.  The  superficial  em- 
bryonal cells  are  transformed  into  pus-corpuscles  as  long  as  the  microbic 
causes  which  produce  the  ulcer  remain  active.  The  products  of  coagula- 
tion-necrosis are  often  deposited  upon  the  surface  of  the  ulcer  in  the  form 
of  a  membrane  more  or  less  firmly  attached  to  the  granulations. 

Membranous  deposits  are  found  more  frequently  upon  ulcerated  sur- 
faces of  mucous  membranes  than  upon  ulcers  of  the  skin.  In  ulcerating 
malignant  tumors  the  surface  of  the  ulcer  is  occupied  by  exposed  tumor- 
tissue,  the  seat  of  infection  with  pus-microbes  and  often  also  with  bacilli 
of  putrefaction.  The  foetor  of  the  discharges  from  ulcers  is  always  due  to 
the  presence  of  putrefactive  bacilli,  which  feed  upon  the  dead  tissue  and 
live  and  multiply  in  the  retained  secretions.  Induration  of  the  base  and 
margin  of  the  ulcer  is  always  suggestive  of  carcinoma.  In  chronic  ulcers 
the  underlying  and  adjacent  tissues  are  often  extensively  infiltrated  and 
dense,  but  this  firmness  and  density  is  something  quite  different  from  the 
circumscribed,  almost  cartilaginous  induration  that  characterizes  the  car- 
cinomatous ulcer.  In  varicose  ulcers  the  whole  leg  is  often  oedematous  and 
hard.  The  margins  of  an  ulcer  are  abrupt  when  the  fioor  of  the  ulcer  cor- 
responds in  size  with  its  surface.  If  the  margins  are  undermined,  the  floor 
of  the  ulcer  is  larger  than  its  surface,  while  the  reverse  is  the  case  when 
the  margins  are  everted  or  sloping.  In  reference  to  kind,  an  ulcer  is  either 
acute  or  chronic.  An  acute  ulcer  is  the  result  of  a  trauma,  burn,  frost-bite, 
followed  by  suppurative  infection,  or  of  an  acute  suppurative  inflammation 
which  has  resulted  in  a  surface  defect.    A  chronic  ulcer  is  one  of  the  results 


ULCEK.  271 

of  a  chronic  inflammation  like  tnbercnlosis  or  syphilitic  infection,  or  it  fol- 
lows localized  impaired  nutrition,  the  consequence  of  prolonged  mechanical 
causes  which  interfere  with  a  proper  blood-supply,  as  is  the  case  in  ulcers 
caused  by  varicose  veins  or  atheroma  of  arteries.  In  shape  an  ulcer  may  be 
round,  oval,  linear,  or  serpiginous.  An  ulcer  is  frequently  called  in  accord- 
ance with  the  primary  cause  which  produced  it,  and  we  speak  of  an  ulcer 
being  traumatic,  syphilitic,  tubercular,  carcinomatous,  malignant,  varicose, 
mercurial,  etc.  The  clinical  behavior  of  an  ulcer  is  often  described  by  such 
terms  as  irritable  ulcer,  inflamed  ulcer,  phagedsenic  ulcer,  etc.,  the  adjec- 
tives having  reference  to  the  most  prominent  symptoms  presented  by  the 
ulcer.  Among  the  general  causes  which  favor  ulcerative  processes  must 
be  enumerated  angemia,  acute  infectious  diseases,  diseases  of  the  cerebro- 
spinal centres,  atheroma,  varicose  veins;  organic  disease  of  the  heart,  kid- 
neys, and  liver;   and  scurvy. 

Diagnosis. — The  differentiation  between  the  different  kinds  of  ulcers 
is  often  an  easy,  but  occasionally  a  very  difficult,  task.  A  correct  diagnosis 
is  an  essential  prerequisite  to  successful  treatment.  In  obscure  cases  it 
is  very  important  to  obtain  an  accurate  and  reliable  clinical  history  with 
special  reference  to  the  nature  of  the  primary  lesion.  In  ulcers  compli- 
cating malignant  disease  it  is  usually  not  difficult  to  ascertain  the  ex- 
istence and  nature  of  the  primary  affection.  Acute  suppurative  affections, 
with  or  without  injury,  followed  by  surface  defects  which  refuse  to  heal, 
result  in  ulcers  the  cause  and  nature  of  which  can  be  readily  ascertained. 
Ulcers  following  the  action  of  caustics,  burns,  and  frost-bite  offer  no  diffi- 
culties in  diagnosis.  The  most  obscure  ulcers  follow  defective  innervation, 
and  develop  as  secondary  lesions  in  the  course  of  different  forms  of  chronic 
infective  diseases,  notably  tuberculosis  and  syphilis.  In  ulcers  due  to  con- 
genital or  acquired  syphilis  the  cautious  observer  can  usually  find  other 
indications  of  syphilis,  and  should  make  careful  search  for  hyperplasia  of 
the  lym])hatic  glands,  especially  those  of  the  occipital  region  and  of  the 
forearm,  so  constantly  present  in  cases  of  constitutional  syphilis.  In 
tuberculosis  of  the  skin  and  mucous  membranes  and  the  different  forms  of 
lupus  the  ulceration  is  usually  preceded  by  nodules,  and  these  can  gener- 
ally be  found  in  the  vicinity  of  the  tubercular  ulcer.  In  cases  of  doubt 
in  the  differential  diagnosis  between  tuberculosis,  syphilis,  and  carcinoma, 
the  microscope  and  inoculation  experiments  will  render  valuable  service. 
The  microscope  can  be  relied  upon  in  making  a  positive  diagnosis  between 
carcinoma  and  the  different  forms  of  granulomata  if  the  sections  are  taken 
from  the  most  recent  and  active  part  of  the  growth.  Inoculation  experi- 
ments can  be  relied  upon  in  making  a  differential  diagnosis  between  syphi- 
lis and  tuberculosis,  as  the  inoculation  will  prove  negative  in  the  former 
and  will  yield  a  positive  result  in  the  latter  affection. 


373  PEINCIPLES    OF    SUEGEEY. 

Treatment. — The  indications  which  must  be  met  in  the  treatment  of 
an  nicer  are:  1.  Eemoval  of  the  primary  essential  canse.  2.  Removal  of 
indirect  canse.  3.  Rest.  4.  Skin-grafting.  The  first  indication  is  readily- 
complied  with  if  the  ulceration  depend  upon  mechanical  causes  which  ad- 
mit of  removal.  An  ulcer  of  the  mucous  membrane  caused  by  a  sharp, 
projecting  margin  of  a  tooth  or  fragment  of  a  carious  tooth  will  heal 
promptly  upon  the  removal  of  the  source  of  irritation.  A  varicose  ulcer 
will  heal  in  a  short  time  if  the  patient  is  placed  in  a  recumbent  position 
with  the  limb  elevated.  A  syphilitic  ulcer,  as  a  rule,  yields  kindly  to  a 
vigorous  antisyphilitic  treatment.  As  ulceration  is  always  caused  by  in- 
fection with  pus-microbes,  a  vigorous  antiseptic  treatment  of  the  ulcer- 
ated surface  is  best  calculated  to  transform  an  ulcer  into  a  healthy,  granu- 
lating surface.  Nothing  has  yielded  better  results  in  my  hands,  in  accom- 
plishing this  object,  than  a  saturated  solution  of  acetate  of  aluminum. 
The  vicinity  of  the  ulcer  should  first  be  thoroughly  disinfected  by  shaving 
and  scrubbing  with  warm  water  and  potash-soap,  after  which  the  ulcer  is 
covered  by  a  thick  compress  of  gauze  wrung  out  in  a  warm  solution  of 
acetate  of  aluminum.  Evaporation  is  prevented  by  applying  over  the  com- 
press gutta-percha  tissue,  mackintosh  cloth,  or  waxed  paper.  If  the  granu- 
lations are  very  flabby  a  10-per-cent.  solution  of  chloride  of  zinc  should  be 
applied  every  three  or  four  days.  The  compress  should  be  kept  moist  and 
changed  daily.  The  removal  of  indirect  causes  calls  for  medicinal  agents 
and  dietetics  calculated  to  improve  the  general  condition  of  the  patient 
and  remove  the  primary  affection.  In  tubercular  ulcerations  it  is  neces- 
sary to  remove  by  excision,  if  possible,  all  of  the  tubercular  tissue.  In 
malignant  ulcers  the  removal  of  the  primary  tumor  fulfills  this  indica- 
tion. In  the  treatment  of  ulcers  of  the  lower  extremities  the  first  thing 
to  be  done  is  to  confine  the  patient  to  his  bed  and  place  the  affected  limb 
in  an  elevated  position.  This  part  of  the  treatment  insures  rest  for  the 
affected  limb  and  exerts  the  most  direct  influence  in  correcting  the  vas- 
cular disturbances.  As  soon  as  the  ulcer  has  been  rendered  aseptic  cica- 
trization and  epidermization  should  be  hastened  by  skin-grafting.  This, 
according  to  the  size  of  the  ulcer,  can  be  successfully  done  either  by  Rever- 
din's  or  Thiersch's  method.  If  the  ulcer  is  aseptic  preliminary  scraping 
is  not  only  unnecessary,  but  harmful. 

The  patient  must  be  cautioned  not  to  use  the  limb  too  soon  after  a 
successful  skin-transplantation,  as  the  new  tissue  at  best  is  but  an  imper- 
fect substitute  for  normal  skin.  Careful  protection  of  the  new  skin  by 
aseptic  hygroscopic  cotton  and  the  wearing  of  elastic-webbing  bandage 
must  be  continued  several  weeks  or  months  after  the  most  successful  skin- 
grafting,  in  order  to  prevent  recurrence  of  ulceration. 


FISTULA.  373 


PISTULA. 


A  fistula  is  a  tubular  ulcer.  It  always  communicates  with  the  pri- 
mary lesion  and  marks  the  course  of  the  suppurative  affection  which  pro- 
duced it.  The  existence  of  the  fistula  is  the  surest  indication  of  the  per- 
sistence of  the  primary  cause.  When  it  communicates  with  a  hollow  viseus 
it  gives  exit  to  part  of  the  secretion  of  that  organ,  and  is  called,  according 
to  the  communicating  organ,  a  bronchial,  pleural,  gastric,  intestinal, 
vesical,  rectal,  uterine,  etc.,  fistula.  If  it  lead  to  a  deep-seated  primary 
tubercular  affection  it  is  called  a  tubercular  fistula.  Tubercular  fistula 
always  follows  the  spontaneous  perforation  or  incision  of  a  tubercular 
abscess  which  fails  to  heal,  and  is  always  paved  its  entire  length  by  tuber- 
cular granulations.  Many  fistulas  in  communication  with  internal  organs 
persist  in  consequence  of  an  obstruction  the  removal  of  which  is  followed 
by  closure  of  the  fistulous  tract.  The  remarks  on  the  etiology,  diagnosis, 
and  treatment  of  ulcer  are  applicable  to  fistula,  with  the  exception  that 
ulceration  is  a  superficial  process,  while  the  presence  of  a  fistula  indicates 
the  existence  of  a  deep-seated  primary  lesion  which  must  be  reached  and 
removed  before  the  conditions  necessary  for  the  successful  treatment  of 
the  fistula  are  established. 


CHAPTEE  XII. 

Suppurative  Osteomyelitis. 

Suppurative  inflammation  of  the  marrow  of  bone  is  an  exceedingly- 
frequent  affection  in  children  and  young  adults.  As  a  primary  disease  it  is 
seldom  met  with  after  the  skeleton  has  become  fully  developed.  The  form 
of  osteomyelitis  that  will  be  considered  here  is  the  so-called  spontaneous 
variety^  which  occurs  without  direct  exposure  of  the  medulla  to  infective 
microorganisms  from  without. 

HISTORY. 

Traumatic  osteomyelitis  following  amputation,  compound  fractures,  or 
gunshot  injuries  of  the  bones  has  been  recognized  for  a  long  time  as  a  dis- 
tinct and  serious  wound  complication,  but  osteomyelitis  occurring  without 
such  injuries  was  not  understood  until  quite  recently.  We  find  no  mention 
of  this  acute  affection  of  bone  until  1705,  when  J.  L.  Petit  gave  a  descrip- 
tion of  an  acute  disease  of  the  long  bones  which  corresponds  with  what  we 
now  understand  by  osteomyelitis.  Similar  allusions  have  been  made  to  it  by 
Gooch,  Pott,  Cheselden,  Hey,  and  Abernethy,  some  of  their  descriptions  be- 
ing sufficiently  accurate  to  enable  us  to  recognize  the  character  of  the  lesion. 
In  1831  M.  Eenaud  published  a  paper  on  "Inflammation  of  the  Medullary 
Tissue  of  the  Long  Bones,"  in  which  he  gives  a  report  of  five  cases  occurring 
after  amputation,  all  having  terminated  fatally. 

Cruveilhier  alludes  to  the  remote  consequence  of  this  afl'ection  when 
he  says:  "The  phlebitis  of  the  bones  is  one  of  the  most  frequent  causes  of 
visceral  abscesses  following  wounds  or  surgical  operations  in  which  the  bones 
are  involved."  Eoux  credits  Nelaton  with  having  devised  the  term  osteo- 
myelitis in  1834,  and  having  published  a  brief  account  of  it  in  1844.  In  1849 
Mr.  Stanley,  in  his  excellent  monograph  on  "Diseases  of  the  Bones,"  gave  an 
accurate  account  of  the  spontaneous  variety  under  the  title  "Suppuration  in 
Bone."  In  1855  Chassaignac  applied  the  term  osteomyelitis  for  the  first  time 
to  the  spontaneous  variety,  reporting  at  the  same  time  four  cases  that  came 
under  his  own  observation.  Among  the  surgeons  who  have  increased  our 
knowledge  of  the  traumatic  variety,  the  names  of  Vallette,  M.  Eoux,  Jules 
Eoux,  Larrey,  Pirogofl,  Lidell,  and  Allen  deserve  well-merited  mention.  In 
1865  W.  Eoser  gave  a  complete  resume,  in  thirty  propositions  of  Avhat  was 
then  known  concerning  the  spontaneous  variety.  On  account  of  the  multi- 
plicity of  the  bone  affection,  and  the  frequency  with  which  the  joints  are 
involved,  he  called  the  disease  "pseudorheumatism."  The  infectious  origin 
of  traumatic  osteomyelitis  has  been  recognized  for  a  long  time,  but  the  spon- 

(274) 


BACTERIOLOGICAL    AND    EXPERIMENTAL    INVESTIGATIONS.  275 

taneous  form  was  believed  to  be  purely  inflammatory  until  Luecke  first  called 
attention  to  its  infectious  cliaracter.  Demme,  A^olkmann,  Schede,  and 
Hueter  have  added  valuable  contributions  to  the  modern  literature  of  non- 
traumatic acute  suppurative  osteomyelitis.  Pasteur  detected  in  osteomyelitic 
pus  a  microbe  which  he  claimed  was  identical  with  the  microbe  found  in 
furuncles;  hence  he  spoke  of  osteomyelitis  as  "furuncle  of  bone.''  The  bac- 
teriological and  experimental  researches  of  Kocher,  Eosenbach,  Passet, 
Krause,  and  Kraske  have  established  the  fact  that  non-traumatic  osteomye- 
litis, like  the  traumatic  form,  is  a  suppurative  inflammation  of  the  medullary 
tissue,  caused  invariably  by  infection  with  pus-microbes.  Primary  suppura- 
tion, in  hone  begins  in  the  medullary  tissue;  hence  it  is  not  correct  to  speah  of 
a  suppurative  ostitis,  as  is  so  frequently  done  among  English  and  American 
authors.  Primary  suppurative  periostitis  is  an  exceedingly  rare  affection; 
C07vsequently,  osteomyelitis  must  he  oonsidered  as  the  most  frequent  of  all  acute 
inflammatory  diseases  'of  lone. 

BACTEEIOLOGIOAL    AND    EXPERIMENTAL    INVESTIGATIONS. 

Active  suppurative  inflammation  in  bone,  when  it  occurs  independently 
of  an  external  wound,  and  consequently  of  direct  infection,  furnishes  one  of 
the  most  interesting,  and,  thanks  to  the  patient  and  persevering  investiga- 
tions of  a  number  of  the  foremost  pathologists,  one  of  the  best-known  forms 
of  purulent  infection.  For  years  it  has  been  contended,  by  some  who  made 
the  etiology  of  acute  osteomyelitis  the  subject  of  experimentation,  that  it  is 
caused  by  a  specific  microbe  not  found  in  other  forms  of  suppuration.  Con- 
vincing evidence,  however,  has  accumulated,  which  seems  to  leave  no  further 
doubt  that  the  ordinary  microbes  of  suppuration  are  the  cause  of  this  form 
of  suppurative  inflammation,  and  that  the  gravity  of  the  symptoms  which 
attended  the  disease,  as  compared  with  other  suppurative  processes,  is  owing 
to  the  anatomical  location  and  structure  of  the  inflamed  tissues,  rather  than 
to  any  difference  in  the  microbic  cause.  Even  before  the  microbic  cause  of 
acute  osteomyelitis  was  understood,  Kocher  believed  that  infection,  in  some 
cases  at  least,  occurred  through  the  intestinal  canal,  and  made  some  experi- 
ments to  prove  this  point.  He  produced  subcutaneous  fractures  artificially 
in  dogs,  and  then  fed  the  animals  large  quantities  of  putrid  material,  and, 
in  some  cases,  succeeded  in  causing  suppuration  at  the  seat  of  injury.  In  his 
clinical  experience  he  also  observed  that  in  many  cases  of  acute  suppurative 
osteomyelitis  the  premonitory  symptoms  ^^ointed  to  the  gastro-intestinal 
canal  as  the  portio  inwasionis. 

Eosenbach  cultivated  the  staphylococcus  from  osteomyelitic  pus  as  early 
as  1881.  In  one  case  the  yellow  and  the  white  staphylococcus  were  found 
together,  in  another  case  the  staphylococcus  alone,  while  in  a  third  case  the 
aureus  and  the  streptococcus  pyogenes  were  cultivated  from  the  same  pus. 


376  PRINCIPLES    OF    SURGERY. 

Rosenbach  produced  the  same  result  in  his  experiments  by  injection  of  a  pure 
culture  of  pus-microbes  from  a  furuncle  of  the  lip,  as  Struck  did  with  cultiva- 
tions from  the  pus  of  osteomyelitis,  and  with  osteomyelitic  pus  injected  into 
the  subcutaneous  connective  tissue  he  produced  an  ordinary  abscess.  Recur- 
rent attacks  of  osteomyelitis,  years  after  the  primary  disease  had  been  ap- 
parently cured,  Rosenbach  explains  by  assuming  that  after  the  first  attack 
some  of  the  microbes  remain  in  the  tissues  in  a  latent  condition  until,  at 
some  subsequent  time,  local  conditions  are  created  which  enable  them  again 
to  display  their  specific  pathogenic  properties.  Struck  obtained,  from  the 
pus  of  an  acute  case  of  osteomyelitis,  upon  gelatin,  an  orange-yellow  culture; 
the  identity  of  this  culture  with  the  staphylococcus  pyogenes  aureus  was 
soon  generally  recognized.  By  injecting  a  pure  culture  into  the  circulation 
of  animals  which  had  been  subjected,  a  few  days  before,  to  injury  of  bone, 
as  contusion  or  fracture,  he  produced  a  suppurative  inflammation  at  the  seat 
of  the  trauma.  Krause  cultivated  from  osteomyelitic  pus  the  staphylococcus 
pyogenes  aureus  and  albus,  which  he  also  found  in  the  effusion  of  joints,  when 
this  occurred  as  a  complication  of  the  disease.  Injection  of  a  pure  culture 
of  these  cocci  into  the  peritoneal  cavity  of  animals  caused  suppurative  peri- 
tonitis. Intravenous  injections,  with  or  without  previous  fracture,  were  fol- 
lowed most  frequently  by  suppuration  in  joints  and  muscles.  If  a  bone  was 
fractured  subcutaneously  before  the  injection  was  made,  he  frequently  ob- 
served suppuration  at  the  seat  of  fracture,  and  from  the  pus  the  staphylococ- 
cus could  again  be  cultivated.  Poci  in  the  kidneys  were  always  present  in 
all  of  these  experiments.  Miiller  succeeded  in  cultivating  the  staphylococcus 
pyogenes  aureus  from  the  yellow  granulations  in  cases  of  acute  epiphyseary 
osteomyelitis.  Rodet  succeeded  in  producing  in  animals  suppurative  osteo- 
myelitis by  intravenous  injections  of  pus-microbes,  without  inflicting  an 
osseous  injury.  The  suppuration,  which  was  generally  circumscribed,  was 
usually  located  near  the  epiphysis;  it  seldom  involved  any  considerable  por- 
tion of  the  shaft.  In  many  cases  separation  of  the  epiphysis  and  suppurative 
arthritis  of  the  adjacent  joint  occurred.  In  the  most  acute  cases  the  animal 
died  within  twenty-four  hours,  without  any  appreciable  changes  in  the  bones 
being  demonstrable  at  the  necropsy.  Young  animals  proved  more  susceptible 
to  inoculations.  Rodet  believes  that  primary  localization  of  the  pus-mi- 
crobes takes  place  in  the  medullary  tissue  at  a  point  close  to  the  epiphyseal 
cartilage.  When  separation  of  the  epiphysis  occurred,  the  pathological  fract- 
ure was  always  found  on  the  side  of  the  diaphysis. 

Lannelongue  made  investigations  concerning  the  bacteriology  of  acute 
osteomyelitis  in  35  cases.  The  staphylococcus  pyogenes  aureus  was  found 
to  be  the  immediate  cause  in  21,  the  staphylococcus  pyogenes  albus  in  7,  the 
streptococcus  pyogenes  in  3,  the  pneumococcus  in  2,  and  in  2  the  specific 
microbe  could  not  be  ascertained.    He  claims  that  it  is  possible  to  distinguish 


BACTERIOLOGICAL    AND    EXPERIMENTAL    INVESTIGATIONS.  377 

by  the  symptoms  between  streptococcous  and  stapliylococcous  osteomye- 
litis, the  fever  in  the  former  being  more  irregular,  the  skin  over  the  affected 
region  much  redder,  with  lymphangitis  and  painful  adenitis.  The  metastases 
due  to  the  streptococcus  are  articular,  synovial,  and  serous,  while  those  caused 
by  the  staphylococcus  are  visceral.  Staphylococcus  is  more  frequently  met 
with  in  young  children.  The  streptococcous  infection  is  less  liable  to  give 
rise  to  extensive  necrosis  than  implication  of  soft  parts.  In  osteomyelitis 
produced  by  the  pneumococcus  suppurative  arthritis  was  a  constant  compli- 
cation. 

Einne,  who  failed  in  producing  metastatic  abscesses  with  pure  cultures 
of  pus-microbes,  rendered  four  rabbits  pysemic  by  injecting  osteomyelitic  pus 
directly  into  the  venous  circulation.  He  used  the  pus  taken  from  a  case  of 
acute  osteomyelitis  with  grave  symptoms,  and  diluted  it  with  distilled  water, 
and  of  such  a  mixture  he  injected  a  Pravaz  syringeful  into  one  of  the  auricu- 
lar veins  of  four  rabbits.  One  died  in  twenty-four  hours,  with  symptoms  of 
toxEemia,  and  the  autopsy  showed  nothing  but  a  beginning  pneumonia  of  left 
lung.  The  other  three  animals  died  seven  to  ten  days  after  the  injection,  and 
in  all  of  them  suppurating  foci  were  found  in  the  kidneys  and  the  muscles 
of  the  heart.  Ko  abscess  in  muscles  or  suppuration  in  joints.  The  plate 
cultures  made  from  the  pus  used  for  the  experiments  showed  the  staph3do- 
coccus  pyogenes  aureus  and  albus  and  the  bacillus  pyocyaneus.  With  the  ex- 
ception of  the  albus,  all  of  the  microbes  were  also  cultivated  from  the  pus 
of  the  metastatic  abscesses.  In  a  later  communication  the  same  author  ex- 
presses the  opinion  that  the  indirect  causes  of  suppurative  osteomyelitis  are 
changes  brought  about  in  the  medullary  tissue  by  the  microbes  and  their 
ptomaines  of  general  febrile  diseases,  such  as  typhus,  scarlatina,  diphtheria, 
etc.,  which  prepare  the  soil  for  the  action  of  pus-microbes,  or  the  disease  is 
produced  by  the  direct  extension  from  a  localized  suppurative  lesion,  as  a 
furuncle,  through  the  lymphatic  vessels,  or  along  vessel-  or  nerve-  sheaths  to 
the  medullary  tissue. 

Jordan  found  in  the  osteomyelitic  pus,  in  3  cases,  pneumococci;  while 
in  6  other  cases  the  disease  was  caused  by  the  typhoid  bacillus.  According 
to  the  same  author,  the  suppurative  inflammation  of  the  medullary  tissue 
may  also  be  caused,  in  exceptional  cases,  by  the  micrococcus  pyogenes  tenuis, 
the  bacterium  coli  commune,  the  bacillus  pyocyaneus,  and  the  micrococcus 
tetragenus.  Lannelongue  and  Achard  found  in  osteomyelitic  pus  the  diplo- 
coccus  pneumonia  of  Fraenkel  as  the  onl}^  and  essential  microbic  cause  of 
the  inflammation.  E.  Fischer  and  Levy  found  the  same  microbe  in  the  pus 
and  blood  of  2  children  suffering  from  osteomyelitis. 

Kraske  has  studied,  from  a  clinical  stand-point,  the  manner  of  infection 
in  cases  of  acute  osteomyelitis.  In  one  case  he  could  trace  the  infection  dis- 
tinctly to  a  furuncle  of  the  lip;  but,  as  a  rule,  he  thinks  that  infection  takes 


S78  PRINCIPLES    OF    SURGEEY. 

place  through  a  wound  or  abrasion  of  the  skin.  Infection  through  the  intes- 
tinal canal  he  considers  possible,  but  not  proved;  more  frequently  it  takes 
place  through  the  respiratory  organs,  and  in  one  case  he  could  locate  the  in- 
fection through  this  route  with  certainty.  He  asserts  that  recurring  attacks 
should  not  always  be  looked  upon  as  the  result  of  former  infection,  but  as  a 
consequence  of  a  new  infection  of  the  old  site. 

CAUSES. 

The  essential  exciting  cause  of  suppurative  osteomyelitis,  both  acute 
and  chronic,  is  the  presence  of  one  or  more  varieties  of  pus-microbes.  Direct 
extension  of  a  suppurative  lesion  through  the  medium  of  lymphatic  vessel- 
or  nerve-  sheaths,  as  Einne  suggests,  may  be  possible,  but  such  a  direct 
connection  between  a  peripheral  suppurating  focus  and  a  central  osseous 
lesion  of  a  similar  nature  can  seldom  be  demonstrated.  Infection  in  most 
instances  takes  place  hy  pus-microdes  ivhich  have  found  their  way  into  the  cir- 
culation from  a  suppurating  wound  or  through  the  respiratory  or  intestinal 
mucous  memdrane,  and  which  localize  in  the  medullary  tissue  prepared  for  their 
reception  hy  anatomical  peculiarities  of  the  capillary  vessels,  or  hy  a  locus 
minoris  resistentice  created  hy  an  injury  or  some  antecedent  pathological  con- 
dition. A  number  of  well-authenticated  cases  have  been  reported  where  a 
subcutaneous  fracture  became  the  starting-point  of  an  attack  of  osteomyelitis 
in  patients  who  suffered  at  the  same  time  from  a  suppurating  wound  in  a  part 
distant  from  the  fracture.  In  such  cases  it  is  reasonable  and  logical  to  assume 
that  pus-microhes  enter  the  circulation  and  are  conveyed  hy  the  hlood-curreni 
to  the  seat  'of  fracture,  where  they  are  arrested  and  find  a  favorahle  soil  for  their 
reproduction  and  the  exercise  of  their  pathogenic  properties.  Such  cases  are 
simply  the  counterpart  of  what  has  been  accomplished  by  experimentation. 
Clinical  experieiue  and  experimental  research  have  shoivn  that  pus-microhes 
localize  in  preference  near  the  epiphyseary  lines  of  the  long  hones.  During  the 
growth  of  bone  this  region  is  supplied  with  new,  growing,  and  imperfectly- 
developed  capillary  vessels:  a  condition  which  cannot  fail  in  favoring  local- 
ization of  floating  microorganisms  in  this  locality.  Neumann  has  also  called 
attention  to  a  peculiarity  of  the  capillary  vessels  in  the  medullary  tissue,  their 
calibre  being  four  times  greater  than  that  of  the  arterial  branches  that  sup- 
ply them:  another  important  anatomical  condition  which  predisposes  to 
localization  of  microbes  in  this  tissue.  Histological  investigation  has  also 
shown  that  the  small  blood-vessels  in  the  medullary  tissue  are  devoid  of  a 
proper  vessel-wall,  and  appear  more  like  channels  or  excavations  than  blood- 
vessels :  another  condition  which  must  yield  a  potent  influence  in  determin- 
ing congestion  in  these  vessels  and  mural  implantation  of  infected  leucocytes 
imder  the  action  of  an  exciting  cause  or  causes.  As  Luecke  has  shown,  and 
as  Einne  again  asserts,  the  medullary  tissue  is  prepared  for  the  action  of  pus- 


SYMPTOMS.  279 

microbes  by  the  causes  which  precipitate  an  attack  of  some  acute  febrile  af- 
fection, as  variola,  typhoid  fever,  scarlatina,  rubeola,  and  diphtheria.  Keen 
has  given  a  good  account  of  all  the  bone-lesions  following  the  continued' 
fevers.  He  found  69  cases,  of  which  23  affected  the  head,  7  the  trunk,  6  the 
upper  and  42  the  lower  extremities.  In  37  cases  the  disease  followed  typhoid 
fever.  As  to  the  date  of  occurrence  in  47  cases,  10  were  within  two  weeks, 
27  from  three  to  six  weeks,  and  10  some  months  after  the  fever.  Keen's  ex- 
planation was  that  the  earlier  cases  probably  resulted  from  thrombosis  and 
the  later  from  enfeebled  nutrition.  Trauma,  if  any,  in  these  cases  was  always 
slight.  Children  and  young  adults  who  have  passed  through  an  attack  of 
any  one  of  these  infectious  diseases  are  strongly  predisposed  to  an  attack  of 
acute  suppurative  osteomyelitis.  Excluding  all  such  influences,  there  is  still 
left  a  large  number  of  cases  where  osteomyelitis  attacks  persons  otherwise 
apparently  in  perfect  health.  My  own  observations  induce  me  to  attribute 
to  exposure  to  cold  an  important  role  as  an  exciting  cause.  I  do  not  wish  it 
to  be  understood  that  exposure  to  cold  alone  could  ever  result  in  an  attack 
of  acute  suppuration  of  the  medullary  tissue.  Pus-microbes  inhabit  persons 
in  perfect  health,  and  they  do  not  cause  disease  as  long  as  the  circulation  re- 
mains normal,  as  localization  does  not  take  place  in  the  absence  of  a  proper 
soil.  If,  however,  in  such  a  person  the  circulation  in  the  medullary  tissue 
is  disturbed  suddenly,  in  consequence  of  a  sudden  or  prolonged  chilling  of 
the  surface  of  the  body,  congestion,  mural  implantation  and  localization  of 
the  floating  pus-microbes  occur  in  a  locality  which  offers  the  least  resistance 
in  such  an  emergency,  and  a  suppurative  inflammation  is  established  in  the 
medullary  tissue.  I  have  repeatedly  observed  cases  of  osteomyelitis  in  boys 
who,  after  active  exercise,  suddenly  became  chilled  by  bathing  in  cold  water, 
or  who,  after  an  exciting  game  of  base-ball,  stretched  themselves  out  on  the 
cold  ground  to  rest.  A  disturbance  of  the  equilibrium  of  the  circulation  from 
any  cause  is  an  important  factor  not  only  in  precipitating  an  attack  of  acute 
osteomyelitis,  but  many  other  local  infective  processes  in  persons  already  in- 
fected with  the  essential  cause. 

SYMPTOMS. 

Acute  suppurative  osteomyelitis  is  usually  ushered  in  by  a  chill  and 
other  symptoms  indicative  of  the  commencement  of  an  acute  suppurative 
affection.  In  some  cases,  even  during  the  earliest  stages,  the  general  symp- 
toms a°re  out  of  all  proportion  to  the  local  lesion,  presenting  a  clinical  picture 
characteristic  of  intense  septic  intoxication.  I  have  observed  several  cases 
of  multiple  osteomyelitis  where  the  patients  passed  into  a  typhoid  condition, 
muttering  delirium,  dry  tongue,  diarrhoea,  and  a  continued  form  of  fever, 
with  a  high  temperature  and  rapid  pulse,  and  died  within  a  week,  before 
the  local  disease  had  made  any  considerable  progress.    In  one  of  these  cases 


380  PEINCIPLES    OF    SURGERY. 

the  patient  was  a  young  lady,  18  years  of  age,  in  whom  the  disease  affected 
both  tibise,  one  femur,  both  humeri,  one  clavicle,  and  several  ribs  from  the 
very  beginning,  and  the  disease  proved  fatal  on  the  sixth  day.  In  such  cases 
the  prominent  general  symptoms  are  those  of  a  malignant  form  of  progress- 
ive sepsis.  It  is  possible  that  the  toxins  produced  by  the  pus-microbes  in  the 
medullary  tissue  may  be  more  virulent,  or  that  they  are  produced  in  larger 
quantities  than  in  suppurative  inflammation  of  other  organs.  Again,  the 
toxins  gain  here  more  ready  entrance  into  the  circulation,  as,  at  least  in  part, 
they  are  produced  within  the  blood-vessels,  and  the  extravascular  products 
are  forced  rapidly  into  the  circulation  on  account  of  the  unyielding  nature  of 
the  tissues  around  the  primary  focus  of  inflammation.  In  some  cases  of  acute 
osteomyelitis  the  actual  development  of  the  disease  is  preceded  by  premoni- 
tory symptoms,  which  indicate  the  route  through  which  infection  has  prob- 
ably taken  place.  A  preceding  bronchial  catarrh  would  indicate  the  pos- 
sibility that  infection  had  occurred  through  the  mucous  membrane  of  the 
respiratory  organs,  while  infection  through  the  intestinal  canal  would  give 
rise  to  diarrhoea  as  a  premonitory  symptom.  The  local  symptoms  will  be 
considered  separately,  as  a  correct  early  diagnosis  can  only  be  made  by  a  care- 
ful study  of  these,  individually  and  collectively. 

Pain. — Pain  is  one  of  the  earliest  and  constant  symptoms  af  acute  osteo- 
myelitis. It  may  be  absent  in  multiple  osteomyelitis,  where  the  patient  passes 
into  a  condition  of  stupor  almost  from  the  beginning.  The  pain  is  described 
by  the  patient  as  being  excruciating,  of  a  boring,  tearing,  or  throbbing  char- 
acter. It  is  not  limited  to  the  area  involved  by  the  disease,  but  is  often  dif- 
fuse, extending  to  the  adjacent  joint  and  oyer  a  considerable  portion  of  the 
shaft.  It  is  caused  by  the  great  tension  resulting  from  the  pressure  of  the 
inflammatory  product  in  a  tissue  surroimded  by  an  unyielding  case  of  com- 
pact bone.  Pain  increases  as  the  exudation  becomes  more  abundant,  and  is 
diminished  or  subsides  almost  completely  with  the  escape  of  the  inflamma- 
tory product  from  the  interior  of  the  bone  into  the  surrounding  soft  tissues. 
Sudden  diminution  of  pain  is  almost  a  certain  indication  that  perforation  of 
the  bone  has  occurred,  and  that  the  pus  has  escaped  into  the  loose  paraperi- 
osteal  tissues.  The  location  of  pain  should  be  carefully  inquired  into,  as  in 
multiple  osteomyelitis  this  symptom  will  show,  at  an  early  time,  the  number 
and  location  of  bones  affected.  In  multiple  osteomyelitis  the  disease  may 
appear  simultaneously  in  several  bones  far  apart,  or  the  disease  appears  in 
one  bone  first,  and  other  bones  are  attacked  later  successively.  The  appear- 
ance of  pain  in  a  new  locality  is  generally  an  indication  that  another  bone 
has  become  involved. 

Tenderness. — The  patient  is  very  seldom  able  to  locate  accurately  the 
primary  focus  of  the  disease  in  an  inflamed  bone,  as  the  pain  is  diffuse;  but 
the  pain  caused  by  pressure  will  enable  the  surgeon  to  locate  the  primary 


SYMPTOMS.  381 

focus  within  the  bone  with  accuracy,  even  before  any  external  swelling  has 
appeared.  During  the  first  few  days  the  area  of  tenderness  will  correspond  to 
the  extent  of  the  disease  in  the  interior  of  the  hone,  and  the  centre  of  this  area 
will  correspond  to  the  primary  focus  of  the  inflammation.  Tenderness  is  most 
acute  where  the  disease  has  approached  nearest  the  surface  of  the  bone,  and 
by  this  means  the  surgeon  locates  the  site  for  early  operation.  Tenderness 
is  caused  by  the  secondary  periostitis.  In  osteomyelitis  of  the  long  bones 
this  symptom  appears  first  near  one  of  the  epiphyses,  and  extends  later 
toward  the  shaft  of  the  bone  as  the  periostitis  ascends  or  descends  in  that 
direction. 

Swelling.- — The  absence  of  external  swelling  during  the  first  few  days 
of  an  attack  of  acute  osteomyelitis  has  often  given  rise  to  mistakes  in  diag- 
nosis. As  the  primary  inflammation  is  located  in  the  interior  of  a  bone,  ex- 
ternal swelling  is  absent  until  the  inflammation  has  extended  to  the  sur- 
rounding soft  tissues.  With  the  appearance  of  the  secondary  periostitis 
swelling  occurs,  which  at  first  can  be  felt  as  a  hard  induration,  soon  followed 
by  oedema  and  deep-seated  fluctuation.  The  rapid  local  diffusion  of  the 
process  is  largely  due  to  the  unyielding  nature  of  the  tissues  around  the 
primary  focus,  and  to  the  fact  that  the  blood-vessels  are  directly  concerned 
in  the  extension  of  the  process  by  becoming  the  channels  for  the  diffusion 
of  the  septic  infection,  their  contents  forming  a  nutrient  medium  for  the 
pus-microbes.  Thrombophlebitis  is  a  constant  and  early  condition  in  every 
case  of  acute  osteomyelitis.  The  oedema  of  the  soft  parts  is  caused,  in  part 
at  least,  by  the  deep-seated  venous  obstruction.  The  external  swelling  sel- 
dom appears  before  the  end  of  the  first  week,  but  when  it  once  shows  itself  it 
increases  very  rapidly.  The  secondary  suppurative  periostitis  results  in  ex- 
tensive denudation  of  the  bone  of  this  membrane,  a  large  portion  of  the  shaft 
being  surrounded  by  pus.  As  soon  as  the  suppurative  inflammation  extends 
to  the  soft  tissues,  diffuse  burrowing  of  pus  takes  place  between  the  bone  and 
the  periosteum  and  among  the  muscles.  Within  a  few  days  an  immense 
abscess  or  a  very  extensive  purulent  infiltration  develops  in  this  manner. 

Redness. — The  skin  over  the  affected  bone  presents  a  pale,  normal  ap- 
pearance until  the  pus  reaches  the  subcutaneous  tissue,  when  it  presents  a 
red  or  brownish-red  discoloration.  The  superficial  veins  are  always  dilated 
and  turgid:  a  reliable  indication  of  the  existence  of  a  deep-seated  thrombo- 
phlebitis. 

Synovitis. — Infiammation  of  joints  situated  in  close  proximity  to  osteo- 
myelitic  foci  is  the  rule.  Catarrhal  synovitis  appears  during  the  first  few 
weeks,  while  suppurative  synovitis  usually  occurs  later  as  a  complication  of 
acute  suppurative  osteomyelitis.  If  the  effusion  into  the  joint  is  of  a  serous 
character,  it  occurs  not  as  a  result  of  infection  with  pus-microbes,  but  in  con- 
sequence of  vascular  disturbances  outside  the  limits  of  the  area  of  infection. 


282 


PEINCIPLES    OF    SUKGERY. 


The  serous  effusion  appears  rapidly,  gives  rise  to  pain  and  contraction  of  the 
joint,  but,  as  a  rule,  disappears  spontaneously  after  the  evacuation  of  pus. 
Suppurative  synovitis  follows  infection  of  a  joint  with  the  same  microbes 
that  caused  the  osteomyelitis,  which  reached  the  joint  either  directly, 
through  some  pathological  defect  of  the  epiphysis,  or  through  the  lym- 
phatics or  blood-vessels. 

The  occurrence  of  an  attack  of  suppurative  synovitis  greatly  aggravates 


Fig. 


105. — Osteomyelitis  of  the  Tibia  in  a  Girl  8  Years  Old,  Two  Weeks  after  Beginning 
of  the  Disease,  showing  Location  and  Extent  of  the  Denuded  Bone. 


the  general  symptoms,  and  is  attended  by  more  serious  local  disturbances 
than  is  the  case  if  the  effusion  is  of  a  non-septic  character.  If  any  doubt  exist 
in  reference  to  the  character  of  the  effusion  an  exploratory  puncture  will 
furnish  the  necessary  information. 

Epiphyseolysis. — Separation  of  an  epiphysis  from  the  diaphysis  in  the 
epiphyseal  line  is  not  an  infrequent  accident  in  cases  of  osteomyelitis  of  the 
long  bones.     It  is  a  pathological  fracture  which  occurs  in  consequence  of 


DIAGNOSIS.  383 

necrosiS;,  inflammator}^  osteoporosis,  or  molecular  disintegration  of  bone  in 
the  epiphyseary  line.  It  is  readily  recognized  by  the  existence  of  a  false 
point  of' motion  and  the  displacements  which  usually  attend  fractures  in 
such  a  locality.  Epiphyseolysis  seldom  occurs  before  the  end  of  the  fourth 
or  sixth  week  from  the  beginning  of  the  attack. 

Loss  of  Function. — In  a  limb  the  seat  of  an  acute  osteomyelitis  all  func- 
tions are  usually  completely  suspended.  It  is  as  useless  as  though  one  of  the 
principal  bones  had  been  fractured.  The  patient  is  unable  to  raise  it,  or  to 
move  the  nearest  joint.  The  limb  is  not  only  useless,  but  the  patient  com- 
plains of  a  sensation  as  though  it  would  break  on  its  being  lifted  or  otherwise 
manipulated. 

DIAGNOSIS. 

Mr.  Holmes  has  well  said  that  acute  suppurative  osteomyelitis  is  more 
frequently  recognized  at  post-mortem  examinations  than  at  the  bedside  of 
the  sick.  It  has  often  been  mistaken  and  treated  for  other  affections,  as 
periostitis,  ostitis,  inflammation  of  joints,  rheumatism,  typhoid  fever,  ery- 
sipelas, and  even  phlegmonous  inflammation  of  the  soft  parts.  "When  we 
remember  that  periostitis,  ostitis,  synovitis,  and  cellulitis  are  secondary 
lesions,  intimately  associated  in  the  clinical  history  of  every  case  of  osteo- 
myelitis, and,  furthermore,  that  the  fever  attending  it  closely  resembles 
typhoid  fever,  it  is  not  surprising  that  mistakes  in  the  early  diagnosis  of  this 
disease  are  not  infrequent,  even  in  the  practice  of  experienced  surgeons.  A 
careful  consideration  of  every  feature  of  the  clinical  picture  presented  by 
each  case  can  only  enable  us  to  arrive  at  correct  diagnostic  conclusions. 
There  is  no  single  pathognomonic  symptom  that  would  infallibly  lead  us  to 
a  correct  diagnosis.  The  presence  of  fat-globules  in  the  pus  was  regarded 
as  diagnostic  by  Chassaignac  and  Eoser.  Fat-globules  are  often  found  in 
osteomyelitic  pus,  but  they  are  not  invariably  present,  and  may  also  occur 
in  the  pus  of  a  phlegmonous  inflammation.  An  important  element  in  dif- 
ferential diagnosis  is  the  absence  of  external  swelling  for  the  first  few  days, 
regardless  of  the  severity  of  other  symptoms;  also,  its  rapid  diffusion  after 
it  has  once  made  its  appearance.  In  periostitis  and  phlegmonous  inflamma- 
tion of  the  connective  tissue  swelling  is  one  of  the  earliest  symptoms.  In 
osteomyelitis  the  superficial  swelling  is  at  first  oedematous,  extends  sym- 
metrically around  the  entire  bone,  and  gradually  diminishes  at  a  point  where 
the  morbid  process  in  the  interior  of  the  bone  has  become  arrested.  In  acute 
cases  fluctuation  appears  about  the  end  of  the  first  or  during  the  second  week. 
A  consecutive  inflammation  of  proximal  joints  usually  makes  its  appearance 
about  from  the  end  of  the  first  to  the  fourth  week.  The  time  of  its  appear- 
ance, as  well  as  its  character,  is  determined  by  the  causes  which  produce  the 
synovitis.    While  joint  affections  are  almost  constant  in  osteomyelitis,  they 


284 


PEINCIPLES    OF    SURGEEY. 


are  seldom  associated  with  periostitis,  or  plastic  osteomyelitis.  In  osteomye- 
litis of  the  tibia  the  phlegmonous  inflammation  sometimes  involves  the 
prepatellar  bursa,  in  which  case  the  swelling  simulates  very  closely  a  com- 
plicating suppurative  synovitis.  The  fluctuation  over  the  knee-joint  is,  how- 
ever, in  such  cases  continuous  with  that  of  the  primary  osteomyelitic  abscess. 
The  character  of  the  fever  which  accompanies  grave  attacks  of  osteomyelitis 
sometimes  obscures  the  local  symptoms  to  such  an  extent  as  to  lead  the  at- 
tendant to  the  belief  that  the  patient  is  suffering  from  an  attack  of  typhoid 
fever.  Goltdammer  has  reported  a  typical  case  of  this  kind.  The  general 
symptoms  simulated  typhoid  fever  so  closely  that  the  patient,  after  an  ill- 
ness of  ten  days,  was  sent  to  the  medical  wards  as  a  severe  case  of  typhoid 


106. — Osteomyelitis  of  Tibia  Two  Weeks  Old,  Complicated  by  Extension  of 
Phlegmonous  Inflammation  to  the  Preepatellar  Bursa. 


fever.  The  pulse  ranged  between  110  and  120;  temperature,  40°  to  41°  C, 
with  tympanites,  dry  tongue,  enlargement  of  spleen,  bronchitis,  rapid  respi- 
ration, and  delirium.  On  close  examination,  a  slight  swelling  was  found  over 
the  lower  part  of  the  right  tibia,  with  tenderness  on  pressure:  symptoms 
which  finally  enabled  the  attending  physician  to  make  a  correct  diagnosis. 
During  the  progress  of  the  case  pleuritis,  parotitis  duplex,  and  synovitis  of 
the  right  shoulder-joint  made  their  appearance.  The  patient  died  eight  days 
after  admission,  or  eighteen  days  from  the  beginning  of  the  disease.  The  ne- 
cropsy revealed  the  existence  of  acute  osteomyelitis  of  the  tibia  and  pyaemia. 
Many  such  cases  have  been  recorded  where  the  differential  diagnosis  between 
acute  osteomyelitis  and  typhoid  fever  was  difficult,  if  not  impossible,  until 
the  local  symptoms  became  more  conspicuous.     The  premonitory  symptoms 


PEOGNOSIS.  285 

in  typhoid  fever  are  more  constant  and  prominent  than  in  osteomyelitis.  In 
the  latter  affection  the  bronchial  or  intestinal  catarrh  which  occasionally 
precedes  the  attack  constitutes  the  only  premonitory  symptom  which  has 
been  observed,  and,  as  a  rule,  the  disease  commences  abruptly  without  any 
such  warnings.  Chassaignac  believes  that  diarrhoea  is  present  in  almost  all 
cases  in  the  beginning,  but  it  is  a  more  constant  symptom  after  septicaemia 
and  pyasmia  have  made  their  appearance.  The  temperature,  as  a  rule,  shows 
less  variation  in  osteomyelitis  than  in  typhoid  fever.  After  the  initial  chill 
and  the  usual  symptoms  attending  the  subsequent  fever,  the  first  symptom 
that  points  to  osteomyelitis  is  pain.  This  is  generally  severe,  deep-seated, 
constant,  boring,  tearing,  or  throbbing  in  character,  and  referred  to  the  pri- 
mary focus  of  the  disease,  usually  in  the  vicinity  of  the  epiphyseal  line. 
Patients  old  enough  to  describe  their  sensations  complain  of  a  feeling  as  if 
the  bone  were  being  broken.  They  object  to  moving  or  handling  of  the 
limb  on  account  of  fear  of  an  aggravation  of  this  distressing  sensation.  E. 
von  Wahl  makes  the  statement  that  fluctuation  is  at  first  circumscribed  in 
phlegmonous  inflammation  of  the  connective  tissue,  while  it  is  dift'use  from 
the  beginning  in  osteomyelitis.  This  distinction  is  a  good  one.  The  im- 
portance of  searching  for  points  of  tenderness  in  the  diagnosis  and  location 
of  the  disease  has  already  been  alluded  to.  The  differential  diagnosis  be- 
tween rheumatism,-  gonorrhoeal  arthritis,  and  osteomyelitis  is  not  difficult, 
as  in  the  former  diseases  the  joint  affections  occur  as  a  primary  disease,  while 
in  osteomyelitis  they  appear  as  complications. 

PEOGNOSIS. 

Modern  aggressive  surgery  has  greatly  diminished  the  mortality  of  acute 
osteomyelitis.  Under  the  old,  expectant,  non-antiseptic  treatment  it  was 
large.  Thus,  Demme  lost  4  out  of  17  cases;  Luecke,  11  out  of  24;  Kocher, 
9  out  of  26;  and  Schede,  3  out  of  23  cases.  Multiple  osteomyelitis,  with 
grave  symptoms  of  septicsemia  from  the  beginning,  almost  without  exception 
proves  fatal  in  less  than  two  weeks.  Death  in  such  cases  is  caused  by  pro- 
gressive sepsis  resulting  from  the  entrance  of  large  quantities  of  toxins  into 
the  circulation.  After  death  no  characteristic  macroscopical  lesion  can  be 
found  in  distant  organs,  and  microscopical  examination  reveals  only  the 
minute  changes  in  the  capillary  vessels  typical  of  acute  septicaemia.  If  the 
patient  escape  this,  the  first  source  of  danger  to  life,  he  is  still  exposed,  dur- 
ing the  existence  of  the  acute  symptoms,  to  the  more  remote  risks  incident 
to  the  presence  of  septic  thrombophlebitis.  If  any  of  the  thrombi  undergo 
softening  and  disintegration,  fragments  reach  the  general  circulation  and 
constitute  infected  emboli,  which  establish  in  distant  organs,  notably  the 
lungs   and   kidneys,    independent   centres    of    suppuration, — the    so-called 


286  PEINCIPLES    OF    SURGEEY. 

metastatic  or  pygemic  abscesses.  The  accession  of  this  fatal  complication  is 
announced  by  recurring  chills,  an  intermittent  form  of  fever,  and  is  followed 
within  a  short  time  by  death  from  sepsis  or  exhaustion.  Another  fatal  acci- 
dent which  may  occur  is  fat-embolism.  The  medullary  tissue  is  liquefied  by 
the  suppurative  inflammation,  and  some  of  the  free  fat-globules  may  be 
forced  into  the  circulation  by  the  intraosseous  pressure,  and  death  is  pre- 
ceded by  rapid,  shallow  breathing;  cyanosis;  small,  rapid  pulse:  symptoms 
which  point  to  the  existence  of  an  obstruction  to  the  passage  of  the  blood 
from  the  right  to  the  left  side  of  the  heart.  Extensive  destruction  of  the 
medullary  tissue  is  always  followed  by  marked  anaemia,  and  this  condition 
is  a  prominent  symptom  in  all  cases  of  osteomyelitis,  as  this  disease  seriously 
impairs  the  function  of  the  myeloid  tissue,  one  of  the  important  blood- 
producing  organs.  Schede  has  seen,  in  cases  of  acute  osteomyelitis,  the 
proportion  of  the  white  to  the  red  blood-corpuscles  increased  to  1-100. 
The  clinical  thermometer  is  an  imjDortant  prognostic  aid  in  this  as  well 
as  in  many  other  acute  infective  processes.  If  the  morning  and  evening 
temperature  remain  continuously  high, — that  is  to  say,  ranges  from 
40°  to  40.5°  C.  during  the  first  week,— it  indicates  a  severe  case.  The 
more  the  general  symptoms  resemble  a  severe  case  of  typhoid  fever,  the 
graver  the  prognosis.  The  occurrence  of  decubitus  is  always  an  unfavor- 
able sign.  In  regard  to  the  function  of  the  limb  after  -an  attack  of  acute 
osteomyelitis,  a  few  words  are  necessary.  jSTecrosis  of  the  bone,  to  a 
greater  or  less  extent,  is  the  rule.  The  extent  of  periosteal  detachment 
during  the  acute  stage  is  no  indication  of  the  area  of  subsequent  seques- 
tration, as  the  greater  part  of  the  denuded  bone  may  receive  an  adequate 
blood-supply  from  the  vessels  within  the  bone,  and  soon  becomes  covered 
with  granulations,  and  later  unites  with  the  periosteum  or  the  paraperiosteal 
tissues.  Joint  affections  and  partial  or  complete  separation  of  one  or  more 
epiphyses  are  frequent  complications.  A  catarrhal  etfusion  is  generally  re- 
moved by  absorption  after  the  subsidence  of  the  acute  symptoms,  and  the 
functions  of  the  joints  are  restored  completely.  If  the  effusion  is  sero-puru- 
lent  and  the  articular  cartilages  remain  intact,  aspiration,  with  subsequent 
washing  out  of  the  joint  with  an  antiseptic  solution,  may  be  sufficient  to  re- 
move the  effusion  and  restore  the  usefulness  of  the  limb.  Stiffness  of  the 
joint  and  malposition  of  the  articular  surfaces  of  the  bones  are  events  that 
cannot  be  avoided  in  all  cases,  even  by  the  most  skillful  and  attentive  treat- 
ment. If  the  articular  cartilages  are  destroyed  by  suppurative  arthritis,  the 
best  result  that  can  be  hoped  for  is  a  useful  limb  with  ankylosis  of  the  joint. 
Pathological  fractures  through  the  shaft  of  a  bone  or  epiphyseolysis  are 
complications  which  greatly  tax  the  duties  of  the  attending  surgeon,  but 
from  which  the  patients  frequently  recover  with  useful  limbs. 


Fig.  107.— Osteomyelitis  of  the  Radius.     Enlargement  of  the  entire  bone  and 
three  well-defined  abscess-cavities. 


PATHOLOGICAL  ANATOMY.  287 


PATHOLOGICAL  ANATOMY. 


Acute  osteomyelitis  is  essentially  a  phlegmonous  inflammation  of  the 
marrow  of  bone.  This  disease  attacks^  preferably,  the  long  bones,  although 
the  scapula,  clavicle,  ribs,  and  ilium  are  also  frequently  affected,  especially 
in  cases  of  multiple  osteomyelitis.  Of  the  long  bones  the  femur  is  most  fre- 
quently affected.  Seventy-three  per  cent,  of  all  of  Demme's  cases  involved 
this  bone.  In  the  femur  the  disease  manifests  a  special  predilection  for  the 
lower  epiphyseal  region,  while  in  the  tibia  the  order  of  frequency  is  reversed. 
The  great  frequency  with  which  the  extremities  of  the  shaft  of  the  long 
bones  are  affected  receives  a  plausible  explanation  from  the  activity  of  the 
physiological  changes  during  the  growth  of  bone,  and  perhaps  to  a  lesser  ex- 
tent by  the  greater  frequency  of  traumatism  in  these  localities.  Englisch 
claimed  that  the  extremity  of  the  shaft  and  epiphysis,  toward  which  the 
nutrient  artery  is  directed,  is  always  primarily  affected,  on  account  of  the 
greater  blood-pressure  in  that  locality.  Clinical  experience  has  proved  the 
contrary.  As  acute  osteomyelitis,  without  direct  exposure  of  the  marrow, 
is  caused  by  infection  with  pus-microbes,  which  reach  the  tissue  through  the 
circulation,  the  inflammatory  process  must  commence  in  the  capillaries  from 
mural  implantation  of  microbes  or  leucocytes  containing  them. 

The  cause  of  the  inflammation  is  primarily  endovascular,  and  reaches 
the  medullary  tissue  with  the  leucocytes.  Intense  alteration  of  the  capillary 
wall  is  always  present  in  these  cases,  giving  rise  to  rhexis.  Pus  from  acute 
osteomyelitis  almost  always  presents  a  reddish  appearance,  which  is  owed  to 
the  presence  of  extravasated  blood.  Oilier  has  described  an  inflammatory 
affection  of  bone  under  the  term  "periostitis  albuminosa."  This  name  was 
suggested  owing  to  the  character  of  the  inflammatory  product,  which  is  of 
a  viscid  nature  resembling  turbid  synovial  fluid.  Oilier  believed  that  this 
pathological  variety  of  osteomyelitis  commenced  in  the  periosteum,  and  was 
distinct  from  the  ordinary  variety  etiologically.  Krause  and  others  on  in- 
vestigating the  bacteriology  of  the  albuminous  product  found  that  it  con- 
tained staphylococci,  consequently  the  same  microbes  so  constantly  found 
in  osteomyelitic  pus.  The  bone  disease  described  by  Oilier  is  a  mild  form 
of  osteomyelitis  characterized  clinically  by  the  absence  of  severe  local  and 
constitutional  symptoms  and  pathologically  by  the  nature  of  the  inflamma- 
tory product  and  the  limited  sequestration.  In  the  acute  variety  of  osteo- 
myelitis the  inflammation  extends  rapidly  to  the  larger  veins,  which  become 
blocked  by  the  formation  of  a  thrombus.  If  pus-microbes  enter  the  throm- 
bosed veins  in  sufflcient  quantity  to  cause  liquefaction  of  the  coagulated 
blood,  pyaemia  results  from  transportation  of  fragments  of  such  infected 
thrombi  to  distant  organs.  Extensive  thrombophlebitis  results  in  arrest  of 
circulation  in  portions  of' the  bone,  or  perhaps  of  the  entire  shaft,  which  is 


288 


PRINCIPLES    OF    SURGERY. 


U'»'l 


kvl 


:*i«5c| 


\X^ 


ve'rr^er. 


Fig.  108.  —  Necrosis  of  Hu- 
merus; Sequestrum  inclosed  by 
Involucrum.     {After  Lebert.) 


followed  by  the  usual  consequences  of  such  a 
condition:  necrosis.  Necrosis  is  undoubtedly 
also  caused  by  the  local  toxic  effect  of  the  tox- 
ins of  the  pus-microbes  upon  the  tissues  and  the 
pressure  resulting  from  the  presence  of  the  in- 
flammatory exudate  in  a  tissue  not  capable  of 
distension.  By  the  coalescence  of  numerous 
small  foci  of  pus  the  central  medullary  cavity 
is  rapidly  transformed  into  an  abscess-cavity. 
The  pus  occupies  either  the  entire  cavity,  a  cer- 
tain section  of  it,  or  is  in  the  form  of  multiple 
circumscribed  abscesses  or  infiltration.  The 
infection  from  the  central  focus  extends  along 
the  blood-vessels  and  soon  reaches  the  perios- 
teum, which  becomes  the  seat  of  an  inflamma- 
tion which  resembles,  pathologically,  the  pri- 
mary medullary  lesion  in  every  respect.  The 
secondary  periostitis  in  every  case  of  acute 
osteomyelitis  always  assumes  a  suppurative  type. 
Pus  accumulates  between  the  periosteum  and 
bone,  causing  often  extensive  denudation  of 
the  bone.  The  periosteum  at  some  points  is 
destroyed  when  the  pus  reaches  the  surrounding 
connective  tissue,  which  then  becomes  the  seat 
of  a  phlegmonous  inflammation.  The  perios- 
teal defects  are  not  restored  subsequently,  and 
at  these  points  openings  remain  later  in  the 
new  bone,  called  cloacae.  After  the  active 
symptoms  have  subsided  the '  suppurative  peri- 
ostitis gives  way  to  a  process  of  repair,  during 
which  the  periosteum  forms  a  case  of  new  bone 
around  the  necrosed  portion,  which,  in  tech- 
nical language,  is  called  an  inwolucrum.  The 
abscess  in  the  soft  parts  heals,  and  one  or 
more  fistulous  communications  between  the- sur- 
face of  the  sldn  and  the  dead  bone  in  the  interior 
of  the  involucrum  remain.  The  external  open- 
ings are  often  quite  distant  from  the  cloacse,  and 
in  such  cases  it  is  difficult,  if  not  impossible,  to 
discover  the  dead  bone  by  probing.  The  ne- 
crosed bone  is  called  a  sequestrum.  If  necrosis 
has  occurred  at  different  points  several  sequestra 


PATHOLOGICAL   ANATOMY.  389 

will  be  included  by  the  involucriim.  Separation  of  a  sequestrum,  like  the 
elimination  of  necrosed  soft  tissues,  is  accomplished  either  by  suppuration 
or,  what  is  more  common,  by  granulation.  Such  pieces  of  bone  always  show 
an  irregular  or  dentated  outline,  which  is  due  either  to  the  original  shape  of 
the  sequestrum  or  to  the  action  of  the  granulations,  which  diminish  the  size 
of  the  detached  bone  after  its  separation.  Necrosis  is  said  to  be  central  if 
the  sequestrum  is  composed  of  tissue  from  the  interior  of  the  bone,  com- 
plete if  it  represent  the  entire  thickness  of  the  bone,  and  cortical  if  it  is  com- 
posed of  the  external  compact  layer  only.  In  complete  necrosis  a  patholog- 
ical fracture  necessarily  takes  place  if  separation  occur  before  a  firm  involu- 


1 

^^K>^ 

1 

Ml  - 

p 

F 

HI 

IB''-. 

1 

R^'S^Hl 

^^Hnn'  '  WH8M 

p^     ' 

E^I^H'^^I 

^         i  *' 

Wk 

a 

1 

Fig.    109. — Sequestra   following   Acute    Diffuse   Suppurative    Osteomyelitis. 
{Pathological  Museum  of  Rush  Medical  College.) 

crum  has  formed.  In  such  cases  restoration  of  the  continuity  of  the  bone  is 
effected  by  the  new  bone.  In  central  necrosis  the  dead  bone  is  always  en- 
cased in  an  involucrum.  In  cortical  necrosis  spontaneous  elimination  of  the 
sequestrum  frequently  occurs  if  the  bone  separate  before  an  involucrum 
forms  around  it,  or,  if  an  involucrum  does  not  form,  on  account  of  destruc- 
tion of  a  corresponding  portion  of  the  periosteum. 

The  medullary  canal  in  the  new  bone,  after  central  or  total  necrosis,  is 
seldom  restored  to  perfection.  The  new  bone  is  harder  and  heavier  than 
normal  bone  (osteosclerosis),  but  in  exceptional  cases  it  remains  porous  and 
soft  (osteoporosis):   a  condition  described  by  Volkmann  and  Schede,  which 


290 


PEINOIPLES    OF    SUEGERY. 


may  become  the  cause  of  yarious  degrees  of  deformity,  from  bending  of  the 
shaft.  Separation  of  a  sequestrum  will  take  place  in  from  four  weeks  to 
three  months,  according  to  the  age  of  the  patient  and  the  location  and  extent 
of  the  necrosis. 


TREATMENT. 


An  early  and  correct  diagnosis  is  of  the  greatest  importance  in  the  treat- 
ment of  acute  osteomyelitis.     As  the  gastrointestinal  canal  is  undoubtedly 


Fig.  110.— Hollow,  Padded,  Posterior  Splint.     (Esmarch.) 


more  frequently  the  route  through  which  infection  takes  place  than  is  gen- 
erally supposed,  and,  as  Nature's  resources  often  attempt  elimination  of  the 
pathogenic  microorganisms  in  this  direction,  it  would  appear  rational  to  ad- 
minister a  brisk  cathartic  soon  after  the  appearance  of  the  first  symptoms. 


Pig.  111.— Board  Splint  for  Upper  Extremity.     (Esmarch.) 

as  such  treatment  might  prove  of  great  value  in  arresting  further  infection 
from  this  source.  A  large  dose  of  calomel,  administered  for  the  same  pur- 
pose and  in  the  same  manner  as  advised  during  the  early  stage  of  typhoid 
fever,  could  not  fail  to  produce  a  salutary  effect.  Kocher  has  advised  the  in- 
ternal use  of  salicylate  of  soda,  giving  from  6  to  34  grammes  in  divided  doses 


TEEATMENT.  391 

during  twenty-four  hours.  In  such  doses  this  remedy  would  also  have  some 
effect  in  reducing  the  temperature,  which  is  constantly  high  in  all  acute 
cases.  Opium  must  be  given  in  sufficient  doses  to  alleviate  pain.  The  af- 
fected limb  should  be  immobilized  and  placed  in  a  slightly  elevated  position. 

Demme,  Billroth,  and  Volkmann  recommend  vesication  by  frequently 
repeated  applications  of  the  strong  tincture  of  iodine.  It  is  doubtful  if  such 
treatment  has  any  influence  in  arresting  or  even  retarding  the  further  devel- 
opment of  the  disease.  The  use  of  the  ice-bag  is  rational,  and  often  relieves 
pain.  In  multiple  osteomyelitis,  with  pronounced  symptoms  of  progressive 
sepsis  almost  from  the  beginning  of  the  attack,  it  is  doubtful  whether  any 
surgical  treatment  will  have  any  effect  in  preventing  a  fatal  termination.  In 
such  cases  general  infection  occurs  almost  from  the  very  beginning,  and  at 
the  necropsy  very  little,  if  any,  pus  is  found  in  the  inflamed  medullary  tis- 
sue.   The  indicatio  vitalis  in  these  cases  calls  for  the  use  of  stimulants. 

One  of  the  most  important  duties  of  the  surgeon,  in  taking  charge  of 


Fig.  112. — Wire  Splint.     {Esmarcli.) 


a  recent  case  of  osteomyelitis  of  any  of  the  long  bones,  is  to  secure  rest  and 
elevation  of  the  affected  limb.  For  the  lower  extremity  a  hollow,  well- 
padded,  posterior  splint,  shown  in  Fig.  110,  will  answer  an  excellent  purpose. 
For  the  upper  extremity  a  wire  or  board  splint  will  secure  the  necessary  de- 
gree of  immobilization.  Immobilization  of  the  limb  in  proper  position  from 
the  very  beginning  of  the  attack  of  osteomyelitis  is  the  most  efficient  prophy- 
lactic measure  against  contractures  of  Joints,  which  follow  so  often  as  remote 
complications.  An  excellent  method  of  immobilization  of  a  limb  after  an 
early  operation  for  osteomyelitis  consists  in  the  application  of  an  interrupted 
plaster-of-Paris  splint,  as  shown  in  Fig.  113.  The  two  parts  of  the  plaster- 
of-Paris  splint  are  connected  by  a  posterior  wooden  splint,  which  is  incorpo- 
rated in  the  plaster  dressing  by  packing  the  spaces  between  the  splint  and 
the  surface  of  the  limb.  By  covering  the  splint  and  its  packed  margins  with 
shellac  varnish  it  is  rendered  impermeable  to  antiseptic  solutions. 

In  regard  to  the  propriety  of  making  early  incisions  the  greatest  diver- 


292 


PKINCIPLES    OF    SUKGEKY. 


sity  of  opinion  has  prevailed  in  the  past.  Previous  to  the  researches  of 
Demme,  early  and  free  incisions  were  practiced  very  generally.  As  the  re- 
sults following  the  treatment  were  frequently  disastrous,  Demme  was  led  to 
adopt  a  more  conservative  course.  He  advised  an  expectant  plan  to  be  pur- 
sued until  the  disease  should  exhaust  itself,  as  it  were,  as  indicated  by  re- 
duction of  temperature  and  cessation  of  the  active  symptoms  of  the  inflam- 
mation, and  then  he  argued  the  propriety  of  making  large  incisions.  For 
the  purpose  of  affording  an  outlet  for  the  pus  Klose  made  early  and  small 
incisions  at  the  junction  of  the  epiphysis  with  the  diaphysis.  Oilier  advo- 
cates early  incision,  combined  with  trephining  of  the  bone.  In  a  commu- 
nication, read  before  the  Academy  of  Paris,  he  claims  that  trephining  is 


llKilllli''}///- 

Fig.  113.— Interrupted  Plaster-of-Paris  Splint. 


applicable  to  all  forms  of  osteomyelitis  with  severe  general  symptoms.  He 
maintains  that  trephining,  even  in  the  most  diffuse  form,  will  arrest  the  in- 
tense pain  by  relieving  pressure;  and  where  the  disease  is  circumscribed  it 
affords  prompt  and  decided  relief.  In  the  acute  form,  he  claims,  trephining 
will  often  prevent  extensive  necrosis  and  fatal  symptoms,  while  in  the  sub- 
acute and  chronic  form  it  removes  the  most  distressing  symptom:  pain.  In 
8  out  of  19  cases  of  early  trephining  he  found  pus;  and  in  10  cases  the  mar- 
row presented  different  morbid  appearances;  while  in  the  last  case,  a  case  of 
acute  osteomyelitis  of  the  femur,  a  large  quantity  of  fluid  blood  escaped. 
Two  of  the  19  cases  died  of  pyaemia. 

Since  osteomyelitis  has  been  recognized  as  a  microbic  disease,  attempts 


TEEATMENT.  293 

have  been  made  to  arrest  it  by  intraosseous  injections  of  germicidal 
solutions.  Hueter  has  employed  parenchymatous  injections  of  sohitions  of 
carbolic  acid  with  decided  benefit  in  the  treatment  of  other  inflammatory 
affections  of  bones  and  soft  tissues.  Kocher  recommended  that  the  soft  tis- 
sues around  the  infected  bone  should  be  disinfected  by  saturating  them  with 
a  solution  of  carbolic  acid,  thrown  in  with  an  ordinary  hypodermic  syringe. 
Later,  the  same  author  suggested  the  propriety  of  making  intraosseous  in- 
jections after  penetrating  the  bone  with  a  small  perforator  and  injecting 
carbolized  water,  thus  reaching  the  primary  focus  of  the  disease.  Theoretic- 
ally, the  suggestion  appears  valuable;  practically,  intraosseous  injections  in 
the  treatment  of  acute  suppurative  osteomyelitis  have  proved  a  failure.  If 
it  is  next  to  impossible  to  abort  even  a  small  circumscribed  suppurative  in- 
flammation in  the  soft  tissues  with  antiseptic  parenchymatous  injections,  it 
is  not  surprising  to  learn  that  the  same  treatment  has  invariably  failed  in 
arresting  suppuration  in  the  interior  of  bones.  Intraosseous  injections  are 
no  longer  used  in  the  treatment  of  acute  suppurative  osteomyelitis. 

Antiseptic  surgery  has  revolutionized  the  treatment  of  acute  suppura- 
tive osteomyelitis.  The  diseased  medulla  is  now  attacked  with  the  same  im- 
punity as  the  soft  tissues  outside  of  the  bones.  The  objections  to  large  in- 
cisions increasing  the  danger  from  sepsis  and  pygemia  are  no  longer  Avell 
founded,  as  incisions  made  under  antiseptic  precautions  for  the  evacuation 
of  pus,  instead  of  increasing  the  risks  of  death  from  sepsis  or  pyemia,  are 
now  considered  the  best  means  to  prevent  these  fatal  complications. 

It  can  now  be  laid  down  as  an  axiom  in  surgery  that  the  medullary  cav- 
ity, in  every  case  of  acute  suppurative  osteomyelitis,  should  be  freely  exposed 
and  submitted  to  direct  and  most  thorough  antiseptic  treatment  as  soon  as  a 
positive  diagnosis  can  he  made.  It  would  be  a  serious  and  unjustifiable  mis  • 
take  to  open  a  healthy  medullary  cavity;  but,  on  the  other  hand,  it  would 
also  be  next  to  criminal  negligence  to  wait  for  fluctuation  before  resorting  to 
operative  treatment  in  a  case  of  acute  osteomyelitis.  The  bone  should  be 
opened,  the  infected  medulla  removed,  and  the  cavity  disinfected  before 
suppuration  has  extended  to  the  periosteum  and  the  surrounding  soft  tissues. 
The  intelligence  and  moral  courage  of  a  surgeon  can  be  nowhere  better  tested 
and  gauged  than  when  he  is  confronted  by  a  recent  case  of  acute  osteomye- 
litis. He  must  be  sure  of  his  diagnosis,  and  this  often  requires  no  ordinary 
erudition  and  diagnostic  skill.  A  positive  diagnosis  made,  he  must  possess 
enough  courage  to  face  the  popular  prejudice  against  early  operation  under 
circumstances  where  success  is  not  always  attainable.  Impressed  with  the 
imperative  necessity  of  operative  interference  from  his  knowledge  of  a  case, 
a  conscientious  surgeon  will  not  flinch  from  his  duty,  even  under  the  most 
unpromising  circumstances.  If  the  responsibilities  and  risks  are  great,  he 
will  do  well  to  fortify  his  course  by  calling  into  consultation  one  or  more  of 


294  "      PRINCIPLES    OP    SUEGERY. 

his  colleagues,  to  protect  himself  against  unmerited  criticism  in  the  future 
or,  perchance,  a  suit  for  malpractice.  An  early  radical  operation  for  osteo- 
myelitis (and  the  author  means  by  this  an  operation  done  as  soon  as  a  posi- 
tive diagnosis  can  be  made,  and  before  any  external  swelling  has  appeared) 
accomplishes  the  following  most  desirable  results:  1.  It  removes  pain.  2. 
It  enables  the  surgeon  to  remove  the  local  cause  of  the  disease  completely  or 
in  part.  3.  It  prevents  extensive  necrosis.  4.  It  is  the  best  prophylactic 
measure  against  fatal  septicaemia  and  pyemia.  5.  It  prevents  extensive  de- 
struction of  the  periosteum  and  other  contiguous  soft  parts.  6.  It  cuts  short 
the  attack  and  expedites  recovery. 

As  we  have  seen,  the  pain  which  attends  osteomyelitis  is  caused  by  the 
intraosseous  tension  and  by  the  secondary  periostitis.  If  the  medullary  cav- 
ity is  opened  freely  before  suppurative  periostitis  has  developed,  the  opera- 
tion removes  the  conditions  which  cause  the  pain,  and  will  therefore  accom- 
plish at  once  what  anodynes  and  external  applications  can  do  but  imperfectly. 
The  removal  of  the  infected  tissues  fulfills  the  etiological  indications  of  the 
disease,  the  removal  of  the  pus-microbes  completely  or  in  part,  which,  with 
thorough  disinfection  of  the  cavity,  prevents  the  further  extension  of  the 
disease.  Keerosis  takes  place  from  the  action  of  the  pus-microbes  and  their 
toxins  on  the  tissues,  intraosseous  tension,  and  vascular  obstruction,  all  of 
which  causes  are  either  removed  or,  at  least,  favorably  modified  by  an  early 
radical  operation.  Limitation  of  necrosis  is  one  of  the  most  marked  results 
of  all  early  aseptic  operations  for  acute  osteomyelitis.  Progressive  sepsis  is 
caused  by  the  introduction  of  pus-microbes  and  their  toxins  from  the  osteo- 
myelitic  focus  into  the  general  circulation;  hence,  there  is  no  better  way  in 
which  this  fatal  complication  can  be  prevented  than  by  the  removal  of  the 
infected  tissues  and  subsequent  disinfection  of  the  cavity,  followed  by  effi- 
cient drainage  and  strict  antiseptic  treatment  of  the  wound.  As  pyaemia  is 
always  caused  by  septic  thrombophlebitis,  no  surer  way  of  guarding  against 
it  could  be  devised  than  the  early  removal  of  the  infected  tissues,  which  may 
include  the  vessels  with  a  beginning  thrombophlebitis.  If  the  interior  of  an 
osteomyelitic  bone  is  rendered  accessible  to  direct  means  of  disinfection,  such 
treatment  will  often,  if  not  invariably,  prevent  the  extension  of  the  suppura- 
tive inflammation  to  the  periosteum  and  surrounding  connective  tissue, 
which  constantly  occurs  when  the  patients  are  treated  upon  the  expectant 
plan.  An  early  radical  operation,  by  limiting  the  necrosis  and  extension  of 
the  inflammation  to  the  surrounding  soft  tissues,  shortens  the  attack,  and  is 
conducive  toward  establishing  at  an  early  time  a  reparative  process  in  place 
of  one  of  destruction.  Pathological  fractures  will  become  less  frequent  com- 
plications in  acute  osteomyelitis  as  soon  as  early  radical  operations  are  more 
generally  adopted.  Early  operations  under  aseptic  precautions,  in  short,  are 
life-saving  operations;  at  the  same  time,  they  will  leave  the  parts  in  a  more 


TREATMENT.  295 

satisfactory  condition  for  rapid  and  satisfactory  repair.  An  early  operation 
I  should  call  one  done  before  secondary  suppurative  periostitis  has  appeared. 
An  intermediate  operation  for  acute  osteomyelitis  is  one  performed  after  sup- 
puration has  occurred  around  the  bone  first  affected,  and  late  operations  are 
undertaken  for  the  removal  of  necrosed  bone. 

Early  Operations. — The  surface  of  the  limb  is  prepared  in  the  same 
manner  as  for  other  aseptic  operations.  The  primary  focus  of  the  disease, 
usually  in  the  vicinity  of  an  epiphyseal  line,  is  accurately  located  by  search- 
ing for  the  tenderest  point.  Over  this  point,  or  as  near  to  it  as  the  nature 
of  the  soft  parts  will  permit,  an  incision  is  made  down  to  the  bone.  As  the 
operation  is  to  be  done  below  Esmarch's  constrictor,  the  soft  tissues  can  be 
carefully  examined  during  every  step  of  the  operation,  and  their  exact  con- 
dition ascertained.  The  skin  and  underlying  fascia  are  cut  through  with  one 
stroke  of  the  knife,  when  the  knife  should  be  laid  aside  and  the  remaining 
tissues,  down  to  the  bone,  are  carefully  separated  with  the  finger  and  peri- 
osteal elevator,  which  can  be  readily  done  by  following  the  intermuscular 
septa.  The  periosteum,  even  at  an  early  stage,  will  be  found  vascular  and 
easily  separated  from  the  bone.  This  structure  is  then  reficcted,  with  the 
soft  tissues,  on  each  side,  and  held  out  of  the  way  with  retractors.  The  bone 
is  then  opened  with  a  small,  round  chisel.  The  trephine  should  never  be 
used,  as  it  is,  to  say  the  least,  a  bungling  and  inefficient  instrument,  while  the 
chisel  is  an  instrument  of  precision.  For  the  first,  or  exploratory,  opening  a 
semicircular  chisel  should  be  used;  in  the  further  steps  of  the  operation 
ordinary  chisels,  such  as  are  used  by  carpenters,  answer  an  excellent  purpose. 
As  the  first  opening  will  probably  be  made  near  an  epiphyseal  extremity,  at 
a  point  where  the  compacta  is  very  thin,  the  chiseling  is  attended  by  no.  diffi- 
culties. The  opening  is  made  directly  toward  the  centre  of  the  bone.  If  no 
pus  has  formed  the  osteomyelitic  focus  is  recognized  by  the  softness  and 
great  vascularity  of  the  tissues  and  the  escape  of  bloody  serum.  If  pus  is 
found  it  will  probably  appear  at  this  time  as  an  infiltration.  The  object  of 
the  operation  is  not  only  to  open  the  bone,  but  to  remove  all  of  the  infected 
tissues.  The  opening  in  the  bone  is,  therefore,  enlarged  in  the  direction  of 
the  shaft  to  the  extent  of  the  disease  in  its  interior.  If  the  suppurative  in- 
flammation is  extensive,  involving  half  of  the  bone,  or,  perhaps,  the  entire 
shaft,  it  is  advisable  to  make  several  incisions  over  the  bone  in  the  same  line 
instead  of  one  large  incision,  thus  avoiding  a  large  wound  and,  perhaps,  in- 
jury of  important  structures;  at  the  same  time  the  interior  of  the  bone  is 
rendered  accessible  to  direct  treatment  by  opening  the  bone  at  the  corre- 
sponding points  and  scraping  out  the  medullary  tissue  contained  in  the  in- 
tervening sections  with  a  sharp  spoon,  the  handle  of  which  can  be  bent  at 
any  desirable  angle.  After  the  whole  cavity  has  been  thoroughly  curetted 
it  is  disinfected  by  pouring  peroxide  of  hydrogen  into  it,  followed  by  irriga- 


296  PRINCIPLES    OF    SURGERY. 

tion  with  a  solution  of  corrosive  sublimate  (1  to  1000)  or  a  5-per-cent.  solu- 
tion of  carbolic  acid,  and  then  dried  and  mopped  out  with  a  lO-per-cent.  solu- 
tion of  chloride  of  zinc.  The  cavity  is  then  packed  with  iodoform  gauze, 
which  is  brought  out  of  the  wound  or  wounds  to  serve  the  purpose  of  a  capil- 
lary drain.  A  copious,  moist,  hot  antiseptic  dressing  is  applied,  and  the  limb 
immobilized  in  proper  position  upon  a  splint.  A  fall  in  the  temperature, 
and  other  signs  of  improvement  soon  after  the  operation,  are  indications  that 
the  desired  object,  primary  disinfection  of  the  osteomyelitic  focus,  has  been 
attained.  If  on  the  following  day  the  temperature  show  no  reduction,  the 
dressings  are  removed,  antiseptic  irrigations  are  again  employed,  and  the 
limb  is  dressed  in  the  same  manner  as  after  the  operation.  Frequent  irriga- 
tions with  a  ^/a-  to  1-per-cent.  solution  of  acetate  of  aluminum,  or  a  weak 
aqueous  solution  of  tincture  of  iodine,  should  be  made,  and  the  limb  confined 
upon  a  suspension  splint.  In  1888  Tscherning  recommended  very  strongly 
early  operative  interference.  He  insisted  that  the  bone  should  be  exposed 
and  opened  in  such  a  manner  that  the  entire  infected  medulla  could  be 
scraped  out.  Karewski  operated  upon  a  number  of  young  children  in  ac- 
cordance with  this  advice  as  early  as  the  third  day  after  the  beginning  of  the 
initial  symptoms,  with  the  result  that  the  disease  was  cut  short  and  necrosis 
was  prevented. 

Intermediate  Operations. — If  a  case  of  acute  osteomyelitis  come  under 
treatment  after  purulent  infiltration  has  occurred  around  the  affected  bone, 
no  time  should  be  lost  in  evacuating  the  pus  by  incision  and  drainage. 
Multiple  incisions  and  numerous  tubular  drains  are  often  required  to  efliect 
complete  evacuation  and  secure  free  drainage.  In  these  cases  operations  on 
the  bone  itself  should  be  limited  to  making  small  openings  in  the  exposed 
portion  of  the  bone  for  the  purpose  of  reaching  its  interior  with  antiseptic 
irrigations.  Large  openings,  under  these  circumstances,  might  lead  to  patho- 
logical fractures.  The  subsequent  treatment  is  conducted  on  the  same  prin- 
ciples as  a  case  of  phlegmonous  inflammation  and  purulent  infiltration  of 
the  soft  parts. 

As  in  the  early  treatment  of  osteomyelitis  by  radical  operation,  the  limb 
must  be  supported  in  a  desirable  position  by  some  kind  of  a  splint.  The  use 
of  a  proper  splint  in  the  treatment  of  acute  osteomyelitis  is  indispensahle.  A 
well-fitting  posterior  splint,  or  the  anterior  suspension  splint  of  K.  N".  Smith, 
secures  rest  for  the  limb,  prevents  contractures  and  subluxation  of  joints, 
and  finally  diminishes  the  frequency  of  pathological  fractures.  Catarrhal 
synovitis  is  treated  by  aspiration,  and  suppurative  synovitis  by  incision, 
drainage,  and  antiseptic  irrigations.  During  the  acute  stage  of  suppurative 
osteomyelitis  the  removal  of  an  entire  shaft  of  a  long  bone  should  be  limited 
to  one  bone  of  the  forearm  or  leg,  as  the  removal  of  the  entire  shaft  of  the 
humerus  or  femur  before  the  formation  of  an  involucrum  of  sufficient  firm- 


TEEATMENT.  297 

ness  to  act  as  an  efficient  support  would  greatly  complicate  the  mechanical 
part  of  the  after-treatment,  and  the  procedure  might  result  in  imperfect 
restoration  of  the  bone  removed.  Where  the  greater  portion  or  the  entire 
shaft  of  a  bone  has  become  necrosed  and  has  separated  at  one  or  both  epi- 
physeal junctions,  it  may  become  necessary  to  remove  it  during  the  acute 
stage  to  avert  death  from  exhaustion  from  profuse  discharges  and  septic 
fever  incident  to  the  presence  of  such  a  large  septic  foreign  body.  It  has 
been  argued  against  such  a  procedure  that  the  bone  would  not  be  regenerated 
after  its  removal.  This  fear,  however,  is  not  supported  by  facts,  as,  when 
the  periosteum  and  the  epiphyses  remain^  a  good,  if  not  perfect,  substitute 
is  reproduced.  Dupley,  Holmes,  McDougal,  Lefort,  Giraldes,  Spence,  Petre- 
quin,  Wilms,  Cheever,  Eopes,  and  Gay  have  each  reported  cases  where  al- 
most complete  reproduction  followed  the  removal  of  the  entire  shaft.  It  is 
very  important,  especially  in  children,  to  preserve  both  epiphyses,  to  prevent 
subsequent  shortening  and  other  deformities  of  the  limb.  Where  the  con- 
tinuity of  a  bone  has  been  destroyed,  either  by  a  pathological  fracture  or  the 
removal  of  a  part  or  an  entire  diaphysis,  which  has  separated  before  the  in- 
volucrum  has  become  sufficiently  firm  to  serve  the  purpose  of  an  efficient 
mechanical  support,  a  suitable  mechanical  support  must  be  applied  for  a 
long  time  to  guard  against  shortening  and  bending  of  the  new  bone.  During 
the  septic  stage  of  acute  osteomyelitis  with  suppurative  synovitis  amputation 
may  become  necessary  to  save  the  life  of  the  patient.  In  exceptional  cases 
the  same  sad  alternative  may  become  a  necessity  after  the  acute  symptoms 
have  subsided,  for  the  purpose  of  removing  the  source  of  exhausting  sup- 
purative discharges.  Our  present  means  of  treating  abscesses,  difEuse  puru- 
lent infiltrations,  and  suppurative  diseases  of  joints  are,  fortunately,  so  per- 
fect and  efficient  that  even  severe  cases  can  be  treated  on  a  more  conservative 
plan,  and  amputation  should  be  restricted  to  extreme  cases  as  a  dernier 
ressort.  Should  signs  of  pygemia  arise,  our  main  reliance  must  be  placed  on 
the  administration  of  large  doses  of  quinine  and  alcohol.  Luecke  has 
obtained  the  best  results  from  large  doses  of  alcoholic  stimulants.  In- 
stances have  been  reported  where  two  pints  of  cognac  were  given  during 
twenty-four  hours  with  decided  benefit.  Osteomyelitic  patients  should  be 
surrounded  by  the  most  favorable  hygienic  influences,  as  fresh  air,  equable 
temperature,  light,  and  an  abundance  of  plain,  nutritious  food.  As  soon  as 
the  acute  symptoms  have  subsided,  iron,  especially  tinctura  ferri  chloridi, 
should  be  freely  administered.  If  osteomyelitis  is  complicated  by  the  coex- 
istence of  other  diseases,  such  as  syphilis,  tuberculosis,  rachitis,  etc.,  the 
treatment  of  the  latter  should  receive  appropriate  attention. 

Late  Operations. — As  late  operations  will  be  considered  the  operative 
removal  of  sequestra.  The  operation  for  the  removal  of  detached  dead  bone 
is  called  necrotomy  or  sequestrotomy.     The  operative  removal  of  a  seques- 


298  PEINCIPLES    OF    SUEGERY. 

trum  should  always  be  postponed  until  complete  separation  has  taken  place 
and  the  involncrnm  is  strong  enough  to  furnish  the  necessary  mechanical 
support.  If  an  operation  is  undertaken  at  an  earlier  time,  there  is  danger  of 
unnecessarily  removing  a  portion  of  healthy  bone  or  of  leaving  a  part  of 
the  sequestrum.  Necrosis  is  not  a  disease,  but  always  a  result  of  a  destructive 
inflammation.  It  is  not  always  easy  to  determine  whether  separation  of  the 
sequestrum  has  taken  place  in  a  given  case.  The  sinus  leading  down  to  the 
dead  bone  may  be  so  tortuous  that  it  is  impossible  to  introduce  a  probe  into 
the  interior  of  the  involucrum.  Again,  if  the  sequestrum  is  felt  with  the 
probe  it  is  often  impossible,  by  any  kind  of  manipulations,  to  ascertain  in 
this  manner  its  mobility,  as  it  is  often  firmly  incased  in  a  bed  of  granula- 
tions. The  time  required  in  separation  of  the  sequestrum  varies  greatly:  a 
whole  phalanx  of  a  finger  may  be  separated  completely  in  four  weeks,  a 
cortical  sequestriun  of  a  long  bone  may  become  detached  in  six  weeks  to  two 
months,  while  the  separation  of  half  or  an  entire  shaft  of  the  large  long 
bones,  as  the  femur  or  humerus,  may  require  from  three  to  six  months.  If 
the  patient's  general  health  is  improving  there  is  no  need  of  haste  in  the 
removal  of  a  sequestrum,  as  there  is  nothing  lost  and  a  great  deal  gained 
by  waiting  until  sufficient  time  has  elapsed  for  separation  to  take  place. 
Sequestrotomy,  if  properly  performed,  is  one  of  the  most  grateful  of  all 
operations,  as  it  is  attended  by  little  or  no  danger  to  life,  and  is  usually  fol- 
lowed by  a  favorable  result.  Its  performance  has  been  greatly^ simplified  by 
the  use  of  ansesthetics  and  Esmarch's  constrictor. 

Since  Esmarch  taught  us  how  to  obtain,  by  a  very  simple  appliance,  a 
bloodless  condition  of  the  limb  during  the  operation,  the  surgeon  can  make 
the  necessary  dissection  with  the  same  degree  of  accuracy  as  in  the  dissect- 
ing-room, thus  avoiding  injury  of  important  vessels  and  nerves,  which  for- 
merly occurred  quite  frequently  even  in  the  hands  of  the  most  accomplished 
surgeons.  Before  the  operation  the  entire  limb  is  disinfected  and  rendered 
bloodless  by  elevating  it  for  a  few  minutes,  when  an  Esmarch  constrictor 
is  applied  on  the  proximal  side  and  some  distance  from  the  seat  of  operation. 
I  have  met,  in  my  practice,  with  two  cases  of  paralysis  of  the  musculo-spiral 
nerve  from  the  use  of  Esmarch's  constrictor,  which  was  applied  about  the 
middle  of  the  arm,  and,  although  both  patients  recovered  perfect  use  of  the 
limb  in  the  course  of  two  to  four  months,  I  have  since  taken  the  precaution 
to  guard  against  such  a  perplexing  accident  by  applying  the  constrictor  over 
the  middle  of  the  deltoid,  and  over  several  thicknesses  of  a  towel  in  order 
to  protect  the  nerves  against  undue  pressure.  Since  I  have  made  use  of  these 
precautions  I  have  had  no  further  accidents  from  elastic  constriction.  In 
an  operation  for  extensive  necrosis  of  the  tibia  the  constrictor  was  applied 
just  above  the  knee,  and  as  soon  as  the  patient  recovered  consciousness  it 
became  evident  that  the  constriction  had  resulted  in  paralysis  of  the  peroneal 


TREATMENT. 


299 


nerve.  More  than  four  months  elapsed  before  function  was  completely  re- 
stored. Since  that  time  I  always  apply  the  constrictor  higher  up,  where  the 
nerves  are  protected  by  a  thick  cushion  of  muscular  tissue,  and  have  seen  no 
more  evil  effects  from  elastic  constriction  of  the  lower  extremity.  Wherever 
it  is  safe  to  make  the  incision  in  the  line  of  one  or  more  fistulous  openings 
this  should  be  done,  but  when  these  are  in  localities  where  there  would  be 
danger  of  wounding  important  vessels,  muscles,  or  nerves,  another  location 


Fig.  114. — Incision  for  Necrotomy  of  the  Tibia. 


must  be  chosen.  In  operations  upon  the  humerus  the  exact  location  of  the 
musculo-spiral  nerve  must  be  remembered,  and  if  the  incision  necessarily 
come  close  to  this  structure  the  dissection  is  made  slowly  and  with  the  use 
of  blunt  instruments  until  the  nerve  is  found,  when  it  can  be  held  out  of  the 
way.  In  operations  upon  the  lower  end  of  the  femur,  even  if  the  fistulous 
opening  should  be  in  the  popliteal  space,  the  incision  down  to  the  bone 
,fhould  be  made  in  the  course  of  the  intermuscular  septum,  on  the  outer  or 


300  PEINCIPLES    OF    SUEGEKY. 

inner  side^,  as  the  posterior  surface  of  the  femur  can  be'  made  accessible  from 
either  side  by  flexing  the  knee  and  by  making  the  incision  large  and  by  keep- 
ing close  to  the  bone,  separating  the  soft  tissues  well  and  keeping  them  out 
of  the  way  by  the  use  of  retractors.  Where  the  bone  is  covered  by  thick 
layers  of  muscles  the  incision  is  made  in  the  direction  of  the  muscles,  and 
at  a  point  corresponding  to  an  intermuscular  septum.  In  extensive  opera- 
tions for  necrosis  of  the  shaft  of  the  tibia  I  now  invariably  employ  the 
S-shaped  incision,  as  it  affords  more  room  and  can  be  sutured  with  less  dif- 
ficulty than  a  straight  incision.  The  external  incision  should  always  be 
large,  so  as  to  afford  plenty  of  space.  As  soon  as  the  intermuscular  septum 
is  reached  the  scalpel  should  be  laid  aside  and  the  parts  carefully  separated 
down  to  the  bone  by  using  the  fingers  or  blunt  instruments.  When  the  bone 
is  reached  the  periosteum  is  incised  and  reflected  with  the  soft  tissues  at- 
tached to  it.  The  opening  of  the  involucrum  is  done  with  the  chisel.  In 
old-standing  cases  the  involucrum  is  as  dense  as  ivory  and  the  chiseling  is 
an  exceedingly  slow  and  laborious  process,  as  only  very  small  chips  can  be 
removed  with  each  cut  of  the  chisel.  The  brittleness  of  the  new  bone  should 
warn  the  surgeon  to  chisel  with  care,  as  otherwise  a  fracture  might  result.  If 
the  chiseling  is  done  at  the  site  of  a  former  opening,  this  opening  is  enlarged 
until  the  sequestrum  is  reached  and  can  be  extracted.  Extraction  of  the 
sequestrum  was  the  sole  object  of  operations  in  the  past;  hence  the  dead 
bone  was  removed  through  a  comparatively  small  opening  in  the  bone,  either 
in  toto  or  after  fragmentation.  Modern  surgery  not  only  seeks  to  remove  the 
dead  bone,  but  to  place  the  cavity  in  the  best  possible  condition  for  rapid 
healing.  The  first  indication  to  be  fulfilled  in  securing  a  favorable  repara- 
tive process  after  the  operation  is  to  obtain  an  aseptic  condition  of  the  cavity. 
This  can  only  be  done  by  exposing  the  interior  of  the  entire  cavity.  Chiseling 
is  continued  until  both  ends  of  the  cavity  are  reached,  when  the  sequestrum 
can  be  lifted  out  and  the  granulations  lining  the  cavity  are  scraped  out  with 
a  sharp  spoon.  Sharp  spoons  of  different  sizes  should  be  at  hand,  as  the 
interior  of  such  cavities  usually  presents  depressions  and  sinuses  which 
can  only  be  dealt  with  successfully  by  the  use  of  different-sized  spoons. 
After  the  mechanical  removal  of  the  infected  tissues  the  cavity  is  washed  out 
with  peroxide  of  hydrogen,  followed  by  a  solution  of  corrosive  sublimate  (1 
to  1000)  or  a  5-per-cent.  solution  of  carbolic  acid,  and  rubbed  out  and  dried 
with  an  aseptic  sponge.  It  is  evident  that  the  healing  of  such  a  cavity,  by 
unaided  resources  of  Nature,  would  be  a  slow  process.  Various  attempts 
have  been  made  to  overcome  the  difficulties  in  the  healing  of  cavities  with 
unyielding  walls.  D.  J.  Hamilton  has  suggested  sponge-grafting.  Neuber 
made  flaps  of  the  skin  from  each  side,  which  he  fastened  to  the  floor  of  the 
cavity  with  sutures  or  bone-nails  (Figs.  116  and  117).  Schede  utilized  the 
blood,  which  he  allowed  to  accumulate  in  the  cavity  after  suturing  the  ex- 


TEEATMENT. 


301 


ternal  parts,  and  obtained  some  excellent  results  with  this  treatment.  If  the 
cavity  is  large  the  writer  always  renders  it  shallow  by  chiseling  away  the  mar- 
gins and  after  disinfection  sutures  skin  and  periosteum  over  it,  making,  of 
course,  provision  for  drainage;  but  he  makes  no  attempt  to  bring  the  soft 
tissues  in  contact  with  the  bone  until  the  wound  is  healed,  when  this  object 
is  readily  accomplished  by  carefully  applied  elastic  pressure  made  by  dress- 
ing and  bandage.  E.  Hahn  advised  the  detaching  of  the  skin  on  each  side 
to  within  an  inch,  at  the  posterior  surface  of  the  limb,  for  the  purpose  of 


Fig.  115. — Bone-cavity  after  Removal  of  Sequestrum  and  Granulations  in 
Necrosis  of  the  Tibia.     (After  Esmarch.) 

better  mobilization  of  the  flaps,  which  are  to  be  united  over  the  centre  of 
the  gutter  by  suturing.  For  a  number  of  years  the  author  has  been  experi- 
menting on  animals  with  decalcified  bone  in  the  healing  of  aseptic  bone- 
cavities,  and  the  experimental  as  well  as  the  clinical  results  obtained  so  far 
have  exceeded  all  expectations.  The  decalcified  bone-chips  are  preserved  in 
an  alcoholic  solution  of  corrosive  sublimate  (1  to  500)  or  a  solution  of  iodo- 
form in  sulphuric  ether.  The  most  essential  condition  for  success,  in  the 
treatment  of  bone-defects  by  implantation  of  decalcified  bone,  is  a  perfectly- 
aseptic  condition  of  the  tissue  to  be  brought  in  contact  with  the  implanted 


302  PRINCIPLES    OF    SURGERY. 

bone.  This  condition  is  easily  procured  in  operations  on  bones  for  lesions 
other  than  those  caused  by  infection  with  pus-microbes,  such  as  tumors, 
echinococcous  cysts,  and  tubercular  and  syphilitic  affections  uncomplicated 
by  suppuration.  In  the  surgical  treatment  of  these  affections,  after  the  re- 
moval of  the  diseased  tissue  the  seat  of  operation  must  be  aseptic,  if  the  ordi- 
nary precautions  in  the  prevention  of  infection  from  without  have  been  ob- 
served. In  such  cases  speedy  healing  of  the  external  wound  and  the  early 
partial  or  complete  reproduction  of  the  lost  bone  are  assured.  The  next 
most  favorable  cases  for  this  procedure  are  circumscribed  osteomyelitic  proc- 
esses in  the  epiphyseal  extremities  of  the  long  bones,  as  we  observe  them  in 
cases  of  primary  circumscribed  epiphyseal  osteomyelitis,  or  in  the  form  of  a 
recurring  attack  in  the  same  place,  perhaps  years  after  a  diffuse  osteomyelitis 
of  the  entire  shaft.  This  method  of  treating  bone-cavities  is  also  applicable 
after  operations  for  necrosis  resulting  from  a  previous  attack  of  acute  sup- 
purative osteomyelitis.  The  cavity  must  be  prepared  for  the  implantation 
of  decalcified  bone  in  the  manner  described  above.  The  implantation  is 
made  before  the  removal  of  the  constrictor,  in  order  that,  after  this  is  done, 


ri«    Ub  Fig.  117. 

Fig.  116.— Inversion  of  Soft  Tissues  on  Each  Side  into  the  Bone-cavity.     (After  Neulier.) 
Fig.  117.— Healing  of  Bone-cavity.     {After  Neuher.) 

sufficient  blood  will  escape  to  fill  the  spaces  between  the  chips,  and  thus  serve 
the  useful  purpose  of  a  temporary  cement-substance.  After  the  cavity  has 
been  dusted  over  lightly  with  iodoform,  the  chips,  which  have  been  washed 
previously  in  an  antiseptic  solution,  are  dried  upon  a  gauze  compress,  and  are 
then  poured  into  the  cavity  until  this  is  packed  with  them  as  far  as  the 
periosteum.  The  first  advantage  derived  from  this  method  of  bone-packing 
is  that  the  chips  serve  as  an  antiseptic  tampon  which  arrests  the  free  oozing 
from  the  surface  of  the  bone,  which  always  takes  place  after  the  removal  of 
the  constrictor.  Some  blood  escapes  betAveen  the  bone-chips  and  coagulates 
at  once,  thus  forming  a  desirable  and  useful  cement-substance  which  per- 
meates the  entire  packing,  and  temporarily  glues,  as  it  were,  the  chips  to- 
gether and  the  entire  mass  to  the  surrounding  tissues.  The  periosteum 
should  be  carefully  preserved  in  exposing  the  bone,  and,  after  implantation, 
is  sutured  over  the  surface  of  the  bone-chips  with  absorbable,  aseptic,  buried 
sutures.  If  the  bone  is  deeply  located,  it  may  become  necessary  to  apply  a 
second  and  third  row  of  buried  sutures  in  bringing  into  accurate  apposition 
other  soft  parts.    The  skin  is  finally  sutured  with  silk.    It  is  of  the  greatest 


TKEATMENT.  ■  303 

importance  to  secure  accurate  apposition  of  the  divided  soft  parts,  in  order 
to  preserve  for  the  subjacent  bone  all  of  its  natural  coverings.  In  some  in- 
stances it  would  be,  undoubtedly,  superfluous  to  secure  any  form  of  drainage, 
as,  when  the  cavity  is  perfectly  aseptic  and  hasmorrhage  is  not  in  excess  of 
requirements,  healing  of  the  entire  wound  would  be  accomplished  under 
one  dressing.  Experience,  however,  has  taught  me  that  tension  arising  from 
extravasation  of  blood  often  exerts  an  injurious  influence  upon  the  process 
of  healing,  and  should  be  carefully  avoided.  As  it  is  desirable  to  heal  as 
much  of  the  wound  as  possible  without  interfering  with  drainage,  an  absorb- 
able capillary  drain  should  be  inserted  in  the  lower  angle  of  the  wound.  A 
string  of  catgut  twisted  into  a  small  cord  answers  an  admirable  purpose.  The 
wound  is  covered  with  a  strip  of  aseptic  protective  silk,  over  which  a  few 
layers  of  iodoform  gauze  are  applied.  Over  this  a  cushion  of  sterile  gauze 
is  placed,  with  a  thick  layer  of  salicylated  cotton  along  its  margins  for  the 
purpose  of  guarding  more  securely  against  the  entrance  of  unfiltered  air. 
The  whole  of  the  dressing  is  retained  by  a  circular  gauze  bandage,  evenly 
and  smoothly  applied.  For  the  purpose  of  securing  absolute  rest  for  the  limb 
it  is  placed  upon  a  posterior  splint  and  kept  in  a  slightly-elevated  position. 
If  no  indications  arise  the  first  dressing  is  not  removed  for  two  weeks,  when 
the  entire  wound  will  usually  be  found  healed  except  a  few  granulations  at 
the  place  where  the  catgut  drain  was  inserted.  A  smaller  antiseptic  com- 
press is  applied  and  the  limb  dressed  in  a  similar  manner.  It  is  prudent  to 
enforce  rest, — not  only  till  the  external  wound  has  healed,  but  until  the  proc- 
ess of  repair  in  the  interior  of  the  bone  has  been  completed,  which  embraces 
a  period  varying  from  four  weeks  to  three  months,  according  to  the  size  of 
the  cavity  and  the  age  of  the  patient.  If  an  operation  for  necrosis  with  im- 
plantation of  decalcified  antiseptic  bone-chips  is  followed  by  sujapuration,  it 
is  an  evidence  that  asepsis  was  imperfect,  and  such  cases  must  be  treated 
upon  the  same  principles  as  suppuration  in  other  localities.  If  suppuration 
take  place  soon  after  the  operation,  and  is  profuse,  it  is  probable  that  all  of 
the  bone-chips  will  have  to  be  removed  in  order  to  facilitate  the  disinfection 
of  the  cavity.  If  it  develop  after  granulation-tissue  has  had  time  to  form, 
and  the  discharge  of  pus  is  moderate  in  quantity,  the  prospects  are  that  the 
bone  will  remain  and  serve  its  purpose  as  a  nidus  for  the  granulation-tissue. 
In  such  cases  an  antiseptic  irrigation  should  be  made  every  three  or  four 
days  until  suppuration  has  ceased.  If  the  bone-chips  are  lost  by  suppuration, 
or  have  to  be  removed  for  the  purpose  of  a  more  thorough  disinfection  of 
the  cavity,  no  attempt  should  be  made  at  reimplantation  until  suppuration 
has  been  arrested;  or,  in  other  words,  until  the  cavity  has  become  lined  with 
granulations  and  is  in  a  comparatively  aseptic  condition  (when  the  time  for 
secondary  implantation  has  arrived).  After  the  cavity  has  been  irrigated 
with  a  strong  antiseptic  solution  the  superficial  granulations  are  removed 


304 


PRINCIPLES    OF    SUEGERY. 


with  a  sharp  spoon,  and  it  is  packed  with  bone-chips,  which  are  implanted 
in  the  same  manner  as  in  the  treatment  of  a  recent  cavity. 

Complete  closure  of  the  external  wound  under  these  circumstances  is 
seldom  obtainable,  and  the  surface  of  the  exposed  portion  of  the  cavity 
should  be  provided  with  a  thin  layer  of  Schede's  moist  blood-clot.  I  have 
resorted  to  implantation  of  decalcified  antiseptic  bone-chips  in  the  treatment 
of  bone-cavities,  after  necrotomy  and  operations  for  tuberculosis  of  bone,  in 
a  great  many  cases,  and  have  had  the  satisfaction  of  healing  large  defects 
without  a  drop  of  pus  under  one  or  two  dressings  in  from  two  to  four  weeks. 
Only  in  a  small  percentage  of  the  cases  was  it  found  necessary  to  remove  the 


Fig.  118. — Osteoplastic  Necrotomy.     (After  Bier.) 


packing,  and  in  most  of  these  secondary  implantation  proved  successful. 
Schede^s  blood-clot  does  not  possess  any  antiseptic  properties,  like  the  bone- 
chips,  and  is  not  as  permanent  a  structure.  Operations  by  Neuber's  method 
are  often  followed  by  necrosis  of  the  flaps,  and  even  if  successful  the  lost  bone 
is  not  restored.  Implantation  of  absorbable  decalcified  antiseptic  bone-chips, 
in  the  treatment  of  aseptic  bone-cavities,  is  preferable  to  the  use  of  viable 
grafts,  as  the  substance  used  is  not  only  absolutely  aseptic,  but  possesses  also 
valuable  antiseptic  properties,  which  must  be  looked  upon  as  a  valuable  and 
very  important  quality  in  the  treatment  of  such  cases.  Eeproduction  of  bone 
follows  almost  to  perfection  in  every  case  where  antisepsis  proves  successful;. 


CHKONIO    OIEOUMSCRIBED    SUPPUEATIVE    OSTEOMYELITIS.  305 

hence  they  serve  the  same  purpose  as  viable  grafts,  as  far  as  the  restoration 
of  lost  tissue  is  concerned.  I  have  chiseled  a  wide  gutter  in  the  humerus 
and  tibia,  almost  from  one  epiphysis  to  the  other,  for  the  removal  of  large 
sequestra,  and  have  seen  such  enormous  defects  restored,  in  a  few  weeks, 
after  implantation  with  bone-chips.  The  contour  of  the  bone  is  restored  to 
such  perfection  that  after  a  few  months  it  would  be  difficult  to  tell  where  the 
operation  was  performed.  The  bone-chips  serve  as  a  temporary  scaffolding 
for  the  granulations  springing  from  all  sides  of  the  bone-cavity,  and  as  they 
are  removed  by  absorption  their  place  is  occupied  by  living  permanent  tissue; 
first  by  embryonal  cells,  which  are  later  converted  into  bone. 

Bier  devised  an  osteoplastic  operation  for  the  removal  of  sequestra  from 
superficial  bones  like  the  tibia.  The  incisions  down  to  the  bone  are  made  in 
the  usual  manner.     The  two  transverse  cuts  through  the  involucrum  are 


Jl) 

!     ' 

V 

^U 

Fig. 

119.- 

•Shulten's 

Method  of  Necrotomy. 

made  with  a  key-hole  saw  and  the  longitudinal  section  with  the  chisel.  With 
an  elevator  the  bone  is  raised,  with  the  overlying  soft  tissues,  like  the  lid  of 
a  box,  thus  freely  exposing  the  interior  of  the  involucrum.  After  the  re- 
moval of  the  dead  bone  and  granulations  the  flap  is  replaced  and  sutured. 
This  operation  is  unnecessarily  severe,  difiicult,  and  tedious,  and  the  disad- 
vantages more  than  overbalance  its  advantages. 

With  a  view  of  closing  the  bone-cavity  (especially  in  operations  upon 
the  tibia)  Schulten  mobilizes  the  two  opposite  walls  and  inverts  them  with 
the  attached  overlying  skin  and  sutures  them  as  shown  in  Fig.  119.  In 
favorable  cases  this  operation  yields  excellent  results. 

CHEONIC    CIECUMSCEIBED    SUPPUEATIVE    OSTEOMYELITIS. 

This  is  the  bone-abscess  of  the  older  authors.  The  etiology  of  this  form 
of  suppurative  inflammation  is  the  same  as  in  the  diffuse  variety.    Clinically, 


306  PKINOIPLES    OF    SUEGERY. 

two  kinds  can  be  distinguished:  1.  Primary  epiphyseal  circumscribed  osteo- 
myelitis. 2.  Secondary  circumscribed  osteomyelitis.  The  first  kind  is  occa- 
sionally met  with  as  a  multiple  affection,  and  is  then  attended  by  more  or 
less  constitutional  disturbances  and  may  result  in  epiphyseolysis.  The  sec- 
ondary form  occurs  in  bones  that  have  been  the  seat  of  an  attack  of  diffuse 
suppurative  osteomyelitis,  the  patient  apparently  having  recovered  com- 
pletely from  the  primary  attack  years  before.  It  is  still  a  question  under  dis- 
cussion if  in  these  cases  the  infection  is  caused  by  microbes  which  have  re- 
mained in  the  tissues  in  a  latent  state  since  the  primary  attack  or  whether  it 
is  caused  by  localization  of  pus-microbes  in  the  tissues  weakened  by  the  first 
attack.  Eosenbach  is  of  the  opinion  that  recurring  attacks  of  osteomyelitis 
in  the  same  bone  are  caused  by  pus-microbes  which  have  remained  in  the 
tissues,  and  which  again  become  pathogenic  when  the  tissues  around  them 
are  rendered  susceptible  to  their  action  by  subsequent  causes.  I  am  strongly 
inclined  to  the  same  opinion.  I  have  seen  numerous  cases  where,  in  per- 
sons from  16  to  25  years  of  age,  repeated  attacks  of  circumscribed  osteomye- 
litis occurred  in  a  bone  which,  during  childhood,  had  passed  through  an  at- 
tack of  acute  osteomyelitis.  The  tibia,  femur,  and  humerus  are  the  bones 
which  are  most  frequently  attacked  by  recurrent  osteomyelitis.  The  sec- 
ondary attacks  occur  either  in  the  centre  of  the  sclerosed  bone,  the  former 
site  of  the  infected  medullary  cavity,  or  near  one  of  the  epiphyseal  lines.  I 
have  no  doubt  that  secondary  osteomyelitis  will  be  of  less  frequent  occur- 
rence after  early  operations  for  osteomyelitis,  and  that  antiseptic  seques- 
trotomy  will  be  more  generally  practiced. 

Symptoms. — The  most  important  symptoms  of  circumscribed  central 
suppuration  in  bone  are  pain  and  tenderness.  The  pain  is  deep-seated,  in- 
tense, of  a  boring  or  gnawing  character,  and  is  generally  more  severe  after 
active  exercise  and  during  the  night.  It  is  often  intermittent,  and  has  fre- 
quently been  wrongly  interpreted  as  neuralgia  of  bone. 

The  tenderness  is  circumscribed,  and  corresponds  to  the  location  of  the 
suppurating  focus.  It  is  due  to  a  circumscribed  secondary  plastic  periostitis. 
The  external  swelling  is  slight,  and  often  completely  wanting.  Usually 
neither  redness  nor  oedema  is  present. 

In  the  diagnosis  of  circumscribed  osteomyelitis  it  is  important  to  re- 
member gummatous  or  syphilitic  osteomyelitis.  The  latter  affection  is  not 
rare  during  the  late  stage  of  syphilis.  It  attacks  the  shaft  as  well  as  the 
epiphyseal  extremities.  Like  osteomyelitis,  gumma  of  the  shaft  of  a  bone 
may  appear  as  a  periosteal,  cortical,  or  central  lesion.  The  central  variety 
may  be  circumscribed  or  diffuse.  The  gummatous  process  may  extend  from 
the  cortex  to  the  medullary  canal  and  vice  versa.  In  gummatous  osteomye- 
litis softening  takes  place  in  the  centre  of  the  swelling  and  hj'-pertrophy  and 
sclerosis  in  the  periphery.     In  the  differential  diagnosis  between  circum- 


Fig.  120. — Central  Syphilitic  Osteomyelitis  of  the  Lower  End  of  the  Femur. 


Fig.  121.— Cortical  Syphilitic  Osteomyelitis  of  the  Femur.     (Frank  Billings.) 


CHKONIC    CIRCUMSCRIBED    SUPPURATIVE    OSTEOMYELITIS. 


307 


scribed  and  gummatous  osteomyelitis  it  becomes  necessary  to  study  carefully 
the  clinical  history  and  to  make  search  for  syphilitic  affections  in  other  parts 
of  the  body. 

Pathological  Anatomy. — Limited  suppurative  osteomyelitis  gives  rise  to 
a  circumscribed  abscess,  which  varies  in  size  from  a  pea  to  a  walnut.  Necrosis 
of  bone  seldom  takes  place;  if  it  does,  the  sequestra  are  small  and  composed 
exclusively  of  cancellated  tissue.  If  the  abscess  is  situated  in  an  epiphysis 
it  may  open  into  the  adjacent  joint  and  become  the  cause  of  a  secondary  sup- 
purative arthritis.  Thrombophlebitis,  sepsis,  and  pygemia  rarely  occur.  The 
periostitis  which  attends  chronic  suppuration  in  bone  always  assumes  a  plas- 
tic type,  as  the  periosteum  is  beyond  the  reach  of  pus-microbes.  Epiphyseal 
osteomyelitis  is  often  associated  with  chondritis  and  osteoporosis:  conditions 
which  may  result  in  pathological  fracture.    If  in  this  form  of  osteomyelitis 


<S5 


^^;^ 


Fig.  122. — Gumma.  Round  and  spindle-shaped  nuclei  imbedded  in  a  granular  and 
fibrillated  matrix  containing  many  multinucleated  giant  cells  with  granular  protoplasm. 
X  200. 

the  suppuration  extend  to  the  periosteum,  a  circumscribed  suppurative  peri- 
ostitis occurs,  which  is  followed  by  the  formation  of  small  abscesses  in  the 
epiphyseal  region.  Limited  necrosis  in  these  cases  is  of  frequent  occurrence. 
Treatment.  —  Circumscribed  osteomyelitic  processes  in  the  epiphyseal 
extremities  of  the  long  bones,  as  we  observe  them  in  cases  of  primary  cir- 
cumscribed suppuration  in  the  epiphyseal  region,  or  in  the  form  of  a  recur- 
ring attack  in  the  same  place  or  in  the  sclerosed  shaft,  perhaps  years  after  a 
diffuse  osteomyelitis  of  the  entire  shaft,  are  favorable  cases  for  implantation 
of  decalcified  antiseptic  bone-chips,  as  an  aseptic  condition  of  the  cavity  can 
be  readily  procured  after  the  operative  removal  of  the  infected  tissues.  The 
inflammatory  focus  can  be  located  externally  with  accuracy  by  the  presence 
of  a  circumscribed  area  of  tenderness,  and  the  centre  of  the  tender  spot  con- 
stitutes the  guide  in  the  search  for  the  abscess.    The  operation  is  performed 


308  TEINCIPLES    OF    SUKGERY. 

under  strict  aseptic  precautions^  and  by  the  bloodless  method.  The  chiseling 
is  done  in  the  direction  of  the  centre  of  the  bone  by  making  a  track  perhaps 
an  inch  square.  If  the  abscess  is  not  found  at  a  certain  depth^  the  surround- 
ing tissue  is  explored  with  a  small  drill  in  different  directions  from  the  track, 
until  it  is  discovered,  when  further  excavation  is  again  made  with  the  chisel. 
As  soon  as  the  abscess  has  been  fully  exposed  the  pus  is  washed  out  and  the 
size  of  the  cavity  ascertained  by  probing.  As  the  abscess  is  often  surrounded 
by  a  zone  of  tissue  infiltrated  with  pus,  all  of  the  infected  tissues  are  scraped 
out  thoroughly  with  a  sharp  spoon,  after  which  the  cavity  is  prepared  for 
the  implantation  of  the  bone-chips  in  the  same  manner  as  in  operations  for 
necrosis.  lodoformization  of  the  cavity  and  the  implantation  of  antiseptic 
bone-chips  are  measures  which  are  well  calculated  to  resist  the  pathogenic 
action  of  pus-microbes  Avhich  might  still  remain,  and  in  the  majority  of 
cases  will  secure  an  aseptic  healing  of  the  wound.  I  have  repeatedly  seen 
cavities  the  size  of  a  small  orange,  in  the  head  of  the  tibia,  heal  under  two 
dressings  by  this  method,  with  perfect  restoration  of  the  bone  removed.  The 
mechanical  means  resorted  to  to  obtain  an  aseptic  condition  of  the  cavity 
will  often  result  in  increase  to  twice  its  original  size,  but  the  loss  of  tissue  is 
TLot  to  he  taken  into  consideration  when  a  method  of  treatment  is  to  be  em- 
ployed which  requires  perfect  asepsis  in  order  to  be  successful  in  placing  the 
parts  in  a  condition  where  perfect  restoration  will  be  accomplished  with 
..almost  unfailing  certainty. 


CHAPTER  XIII. 

SuppuKATiON  IN  Large  Cavities;   Abscess  of  Internal  Organs. 

The  suppurative  affections  of  the  different  large  cavities  in  the  body 
present  so  many  features  common  to  all  of  them  that  they  will  be  con- 
sidered together  in  this  chapter.  Suppurative  inflammation  of  a  mem- 
brane, synovial  or  serous,  lining  a  closed  cavity,  is  characterized  by  the 
rapidity  with  which  the  inflammatory  process  spreads  over  the  entire  sur- 
face, and  the  retention  of  the  products  of  inflammation  in  a  preformed 
closed  space.  Abscesses  of  internal  organs  result  from  infection  by  the 
extension  of  a  suppurative  lesion  from  the  surface  along  the  course  of 
blood-vesels,  lymphatics,  nerve-sheaths,  or  by  the  localization  of  pus- 
microbes  floating  in  the  blood  in  a  locus  mimoris  resistentm  of  an  organ. 

suppurative  arthritis. 

Suppurative  inflammation  in  an  intact  joint  is  always  caused  by 
localization  of  pus-microbes  in  the  synovial  membrane,  conveyed  to  this 
structure  by  the  blood,  which  results  in  suppurative  synovitis,  and,  by  the 
extension  of  the  infection  to  the  other  structures  of  the  joint,  is  often 
followed  by  complete  disorganization  of  the  joint  (panarthritis).  In  this 
manner  metastatic  suppurative  synovitis  is  caused,  as  it  occurs,  in  pysemia, 
gonorrhoea,  and  in  some  of  the  general  infective  diseases. 

Bacteriological  Researches. — In  animals  susceptible  to  the  action  of 
pus-microbes,  the  injection  into  a  joint  of  a  pure  culture  is  usually  fol- 
lowed by  acute  suppuration,  and,  not  infrequently,  by  the  formation  of 
extensive  paraarticular  abscesses.  Hoffa,  Kranzfeld,  and  Krause  have 
studied,  with  special  care,  the  microbic  origin  of  suppurative  synovitis, 
and  all  of  them  found  in  the  pus  one  or  more  varieties  of  the  microbe  of 
suppuration.  Krause  found,  in  the  pus  of  suppurating  joints  in  small  chil- 
dren, a  streptococcus  the  identity  of  which  with  the  one  described  by 
Eosenbach  was  proved  by  cultivation  experiments.  In  one  case  the  same 
microbe  was  also  found  in  the  products  of  a  purulent  meningitis,  which 
followed  in  the  course  of  the  joint  disease. 

The  pneumococcus  has  been  repeatedly  found  as  the  only  microbic 
cause  of  suppurative  inflammation  of  joints.  Tournice  and  Courmont  re- 
port such  a  case.  The  patient  was  50  years  of  age,  the  subject  of  second- 
ary syphilis  and  pneumonia;  during  the  course  of  the  latter  disease  an 
arthritis  developed  on  the  sixth  day.  Other  serous  surfaces  became  in- 
volved, and  the  patient  died.     They  conclude  from  this  and  other  cases 

(309) 


310  PEINCIPLES    OF    SURGERY. 

that  arthritis  due  to  infection  with  pneumococci  difEer  widely  in  the  in- 
tensity of  the  inflammation  from  a  simple  serous  effusion  to  complete  dis- 
organization of  the  joint.  The  pneumococci  are  always  found  in  the  pus 
of  the  affected  joints. 

Vogelius  reports  two  cases  of  croupous  pneumonia  complicated  hy 
suppurative  arthritis,  in  which  the  pneumococci  were  found  in  the  joint 
effusion.  He  also  collected  11  similar  cases  from  the  current  literature. 
In  the  majority  of  cases  this  complication  made  its  appearance  during  the 
first  five  days,  but  in  1  not  until  the  eleventh  day.  The  joint  effusion  was 
purulent  in  6  cases,  sero-purulent  in  2,  and  sero-fibrinous  in  1.  In  the 
remaining  2  the  nature  of  the  inflammatory  product  is  not  mentioned. 


Fig.  123. — Bacillus  Typhosus.     Twenty-four-Hour  Culture  on  Agar-agar. 

Another  microbe  which  has  been  isolated  from  suppurating  joints  as 
the  only  microbic  cause  of  the  inflammation  is  the  bacillus  of  typhoid 
fever.  Eobin  and  Serrede  have  studied  the  forms  of  typhoid  fever  compli- 
cated by  inflammation  of  joints,  as  well  as  grave  joint  affections  accom- 
panied by  typhoid  symptoms.  They  distinguish  the  following  groups  of 
cases:  1.  Those  in  which  the  onset  is  marked  by  acute  swelling  and  pain 
in  the  joints,  but  in  which  the  subsequent  clinical  course  revealed  typhoid 
fever.  These  cases  they  call  arthro-typhoid,  analogous  to  pneumo- 
typhoid.  2.  Cases  of  typhoid  in  which  the  arthritis  always  terminates  in 
suppuration  and  is  due  to  infection  with  the  typhoid  bacillus.  3.  Septic 
disease  of  joints  in  which  the  typhoid  condition  is  due  to  septic  intoxica- 
tion. 


SUPPUEATIVE    ARTHEITIS. 


311 


Meunier  reports  a  case  in  which  the  pneumococcus  and  streptococcus 
were  found  at  the  same  time  in  the  pus  removed  by  aspiration  from  a  sup- 
purating joint.  Bernarbeig  collected  10  cases  of  articular  complications 
in  diphtheria.  The  larger  Joints  are  usually  affected.  The  joint  disease 
developed  from  the  seventh  to  the  fifteenth  day  after  the  onset  of  diph- 
theria. In  the  severe  cases  the  joints  suppurated,  the  suppuration  being 
caused  by  a  secondary  mixed  infection  with  the  streptococcus  pyogenes. 
The  milder  forms  of  joint  disease  they  attributed  to  the  toxins  of  the  diph- 
theria bacillus. 

The  same  streptococcus  was  found  by  Huber  and  Bahrdt  in  pus  from 
a  suppurating  joint,  and  in  the  diphtheritic  membranes  of  a  scarlet-fever 


Fig.  124. — Micrococcus  Gonorrhoeae.  From  male  urethra  seven  days  after  exposure 
to  infection.  Leucocytes  and  two  urethral  lining  cells  are  shown.  (Stained  with  Loeff- 
ler's  methylene-blue.) 


patient.  The  so-called  gonorrhoeal  rheumatism  is  a  suppurative  synovitis, 
but  opinions  are  divided  in  reference  to  the  pyogenic  properties  of  the 
gonococcus.  The  microbe  was  discovered  in  gonorrhoeal  pus  by  Neisser, 
in  1879.  Its  direct  etiological  relation  to  gonorrhoea  has  been  sufficiently 
demonstrated  by  experimental  research  and  clinical  observation.  The 
gonococcus  always  occurs  in  pairs,  and  is,  therefore,  a  diplococcus. 

The  cocci  appear  as  hemispherical  bodies,  with  their  flattened  surfaces 
in  apposition,  which  imparts  to  the  microbe  the  characteristic  biscuit- 
shaped  appearance.  They  are  found  in  clusters  upon,  or,  what  is  more 
probable,  as  Bumm  asserts,  within  the  pus-corpuscles  of  gonorrhoeal  pus. 
Their  intracellular  location  was  shown  by  Bumm,  by  examining  pus- 
corpuscles  in  water;    when,  after  imbibition  of  fluid,  the  cells  become 


313  PKINCIPLES    OF    SURGEEY. 

swollen,  the  cocci  could  be  seen  between  tlie  molecular  granules  of  the 
protoplasm.  The  microbes  within  the  corpuscles  may  become  so  numerous 
as  to  fill  the  entire  space,  with  the  exception  of  the  nucleus.  It  can  be 
cultivated  upon  solidified  blood-serum  or  agar-agar  meat-peptone.  Its 
pus-producing  property  in  specific  inflammation  of  the  mucous  membrane 
of  the  urinary  organs  and  conjunctiva  is  well  known,  and  at  present  is 
not  attributed  to  its  direct  effect  on  the  tissues,  but  to  the  action  of  the 
toxins  which  it  produces.  Many  cases  have  been  reported  which  appear 
to  show  that  under  certain  circumstances  the  microbe  enters  the  circula- 
tion and  becomes  the  cause  of  metastatic  suppuration,  especially  in  joints. 
Schwarz  asserts  that  the  gonococcus  is  constantly  found  in  the  effusion 
of  joints  in  gonorrhoeal  rheumatism,  in  other  abscesses  caused  by  gonor- 
rhoea, and  in  the  glands  of  Bartholin,  in  women  who  have  passed  through 
an  attack  of  gonorrhoea.  Petrone  detected  the  gonococcus  in  the  effusion 
of  joints  and  in  the  blood,  in  two  patients  suffering  from  gonorrhoeal 
rheumatism.     He  regards  the  joint-complications  as  metastatic  processes 


Fig.  125. — Gonococcus.  A,  from  a  pure  culture.  B,  from  a  blennorrhceic  con- 
junctival secretion;  an  epithelial  cell  covered  with  cocci;  a  pus-corpuscle  with  cocci 
in  the  protoplasm;  a  pus-corpuscle  completely  filled  with  cocci;  a  free  mass  of  cocci  in 
close  proximity  to  a  pus-corpuscle.    C,  development  of  gonococci.     (Bumm.) 

caused  by  the  gonorrhoeal  infection.  Other  authors  found  metastatic 
abscesses  in  gonorrhoeal  patients,  cultivated  from  the  pus-microbes  of  sup- 
puration, and  on  this  account  regard  them  as  the  result  of  a  secondary  or 
mixed  infection.  If  gonococci  can  transform  epithelial  cells  of  the  urethra 
or  conjunctiva  into  pus-corpuscles,  there  is  no  reason  to  doubt  that  under 
favorable  circumstances  they  can  exercise  the  same  pathogenic  effect  on 
other  tissues,  particularly  the  synovial  membrane  of  joints.  The  pyogenic 
properties  of  gonococci  in  other  localities  than  the  mucous  membrane 
of  the  urinary  tract  can  no  longer  be  doubted.  It  has  been  found  as  the 
only  microbic  cause  in  fatal  cases  of  endocarditis  and  in  the  pus  of  ab- 
scesses in  different  parts  of  the  body.  In  joints  it  may  produce  a  meta- 
static inflammation  which  results  in  a  fibrinoplastic,  serous,  or  purulent 
product,  according  to  the  intensity  of  the  infection  or  the  receptivity  of  the 
patient  to  the  pathogenic  action  of  this  microbe. 

Symptoms  and  Diagnosis. — Suppurative  arthritis  is  usually  attended 
by  a  great  deal  of  pain.     This  symptom  is  a  prominent  one  in  this  affec- 


SUPPUEATIVE    ARTHEITIS.  313 

tion  on  account  of  the  intensity  of  the  inflammation,  and  also  because 
the  pus  accumulates  with  great  rapidity  in  the  joint,  causing  tension.  Noc- 
turnal exacerbations  are  common.  The  pain  is  greatly  aggravated  by  pass- 
ive motion,  and  any  attempt  on  the  part  of  the  patient  to  use  the  joint 
vastly  increases  the  suffering.  Flexion  of  the  joint  is  an  early  symptom, 
and  increases  in  degree  with  the  progress  of  the  disease.  In  suppurative 
inflammation  of  the  hip-  and  knee-  joints  it  is  not  uncommon  to  find  the 
limb  fixed  at  right  angles.  In  advanced  cases  of  suppurative  gonitis  the 
tibia  becomes  partially  dislocated  backward  and  rotated  outward.  The 
swelling,  as  long  as  it  is  caused  by  the  effusion  into  the  joint,  is  propor- 
tionate to  the  amount  of  fluid  contained  in  the  joint.  In  the  knee-joint 
the  patella  is  raised  from  the  condyles  of  the  femur,  the  depressions  on 
each  side  of  it  are  effaced,  and  the  upper  recesses  of  the  synovial  sac  be- 
come prominent.  After  perforation  of  the  capsule  the  pus  escapes  into 
the  loose  paraarticular  connective  tissue,  where  it  causes  a  rapidly-spreading 
phlegmonous  inflammation.  In  very  acute  cases  rupture  of  the  capsule 
and  an  extensive  paraarticular  abscess  may  appear  in  less  than  a  week. 
With  the  rupture  of  the  capsule  of  the  joint  the  pain  is  diminished,  but 
the  general  symptoms  are  aggravated.  The  parts  around  a  suppurating 
joint  usually  present  an  cedematous  appearance.  The  clinical  history  is 
often  of  great  value  in  arriving  at  a  conclusion  in  reference  to  the  char- 
acter of  the  synovitis.  If  an  arthritis  develop  insidiously  in  connection 
with  a  suppurating  lesion,  attended  by  grave  general  symptoms,  it  is  an 
evidence  which  renders  a  diagnosis  of  pyaemia  more  than  probable.  In 
pygemia  the  joint  affections  appear  often,  either  simultaneously  or  in 
rapid  succession,  as  multiple  affections.  An  obstinate  joint  affection,  ap- 
pearing in  the  course  of  an  attack  of  gonorrhoea,  is  generally  either  a  sero- 
purulent  or  suppurative  synovitis.  Gonorrhceal  synovitis  develops  most 
frequently  from  the  second  to  the  fourth  week  after  the  appearance  of  the 
primary  disease.  If  any  doubt  exist  as  to  the  character  of  the  effusion 
into  a  joint,  this  can  be  readily  dispelled  by  making  an  exploratory  puncture 
with  an  ordinary  hypodermic  needle. 

Treatment. — The  only  form  of  suppurative  synovitis  amenable  to  any 
other  treatment,  short  of  free  incision,  drainage,  and  antiseptic  irrigation,  is 
the  sero-purulent  effusion  complicating  gonorrhoea.  In  such  cases  the  treat- 
ment by  aspiration,  irrigation  with  a  3-per-cent.  solution  of  carbolic  acid,  fol- 
lowed by  comxpression  of  the  joint  and  fixation  of  the  limb  in  an  immovable 
dressing,  is  usually  successful  in  permanently  removing  the  effusion.  In 
gonorrhoeal  joints  and  in  joints  the  seat  of  secondary  infection  in  pysemic 
patients  I  have  obtained  very  satisfactory  results  from  repeated  tapping 
followed  by  injection  with  a  5-per-cent.  solution  of  carbolic  acid.  The  ab- 
sorption of  the  products  of  inflammation  and  return  of  function  are  has- 


314  PRINCIPLES    OF    SUEGERY. 

tened  by  massage  and  hot  and  cold  douches.  If  a  joint  contain  pus,  tem- 
porizing measures  should  be  abandoned,  and  the  pus  should  be  evacuated 
either  by  aspiration  followed  by  washing  out  with  an  antiseptic  solution, 
which  should  be  repeated  until  the  fluid  returns  clear,  or,  what  is  prefer- 
able in  the  vast  majority  of  cases,  the  joint  is  treated  from  the  beginning 
as  an  ordinary  abscess.  For  irrigation  of  a  suppurating  joint  after  in- 
cision, a  Va'Psr-cent.  (0.5  per  cent.)  solution  of  acetate  of  aluminum 
should  be  used.  If  the  aspirator  is  used  for  evacuation  and  intraarticular 
medication,  the  greatest  care  must  be  exercised  not  to  inject  atmospheric 
air  into  the  joint,  as,  aside  from  the  danger  of  increasing  the  affection 
by  the  admission  of  air,  such  accidents  have  been  followed  by  immediate 
death  from  air-embolism.  The  most  efficient  treatment  in  cases  of  sup- 
purative arthritis  is  incision  and  drainage  under  strictest  aseptic  precau- 
tions. As  in  the  treatment  of  acute  abscesses,  the  incisions  must  be  made 
in  places  where  drainage  is  most  required.  A  long  pair  of  hsemostatic 
forceps  is  an  indispensable  instrument  in  draining  a  joint.  In  draining 
the  knee-joint  three  transverse  tubular  drains  should  be  inserted:  one 
beneath  the  tendon  of  the  patella,  one  under  the  patella,  and  one  across 
the  upper  recess  of  the  joint.  The  fourth  drain  should  be  passed  directly 
through  the  joint  between  the  condyles  of  the  femur,  reaching  from  one 
side  of  the  patella  into  the  popliteal  space.  This  would  require  eight  in- 
cisions, each  from  V2  to  1  inch  in  length;  half  of  them  serve  as  openings 
into  the  joint  for  the  forceps,  while  in  making  the  remaining  incisions  only 
the  skin  and  fascia  are  cut  to  the  requisite  extent  over  the  point  of  the  for- 
ceps. In  tunneling  the  soft  tissues  in  the  popliteal  space,  with  the  forceps, 
from  within  outward,  the  opening  is  to  be  made  to  one  side  of  the  large 
vessels  and  nerves.  Such  an  operation  requires  the  administration  of  an 
anaBsthetic  and  the  use  of  elastic  constriction  of  the  limb. 

As  soon  as  all  the  drains  are  inserted  the  joint  is  washed  out  in  dif- 
ferent directions  with  one  of  the  stronger  antiseptic  solutions,  after  which 
a  copious  antiseptic  dressing  is  applied  and  the  limb  is  immobilized  upon  a 
splint.  If  on  the  following  day  the  fever  has  not  subsided,  or  as  soon  as 
the  dressing  has  become  saturated  with  the  discharges,  it  is  removed 
and  the  irxigation  repeated  as  before.  As  soon  as  suppuration  diminishes, 
through  drainage  is  dispensed  with  and  the  drains  are  shortened  from  time 
to  time,  to  be  entirely  removed  with  the  disappearance  of  the  swelling 
and  the  cessation  of  suppuration.  The  elbow-joint  can  be  efficiently 
drained  by  passing  a  drain  transversely  through  the  joint,  between  the  ar- 
ticular surfaces  of  the  humerus,  radius,  and  ulna.  In  draining  the  ankle- 
joint  a  small  incision  is  made  down  into  the  joint,  at  a  point  corresponding  to 
the  anterior  margin  of  the  external  malleolus,  through  which  a  hsemo- 
static forceps  is  introduced  and  piished  in  a  backward  direction,  along  the 


ENDOCKANIAL    SUPPUEATION.  315 

upper  surface  of  the  astragalus,  until  its  point  can  be  felt  posteriorly  under 
the  skin,  to  the  outer  side  of  the  tendo  Achillis.  The  skin  is  then  incised, 
the  opening  enlarged  by  unlocking  the  forceps  and  separating  its  blades, 
and  a  fenestrated  rubber  drain  drawn  through.  If,  as  it  so  often  happens, 
the  posterior  portion  of  the  capsule  of  the  joint  bulge  considerably,  this 
can  be  drained  by  a  drain  inserted  transversely  underneath  the  Achilles 
tendon  near  its  attachment  to  the  os  calcis.  Through  drainage  of  the 
shoulder- joint  in  an  antero-posterior  direction  can  be  established  in  the 
same  manner  without  much  difficulty.  Drainage  of  the  hip-joint  is  always 
difficult  and  never  efficient.  The  best  plan  to  follow  is  to  open  the  joint 
from  behind  through  an  incision  three  or  four  inches  in  length,  and  then 
to  pass  a  long  pair  of  Pean's  or  polypus  forceps  between  the  capsule  and 
the  neck  of  the  femur,  either  along  the  upper  or  lower  border,  in  the  di- 
rection of  the  groin,  and  to  make  a  counter-incision  upon  the  point  of  the 
instrument,  and  to  draw  a  tubular  drain  through  the  whole  length  of  the 
track.  The  wrist-joint  can  be  drained  transversely  and  antero-posteriorly, 
without  fear  of  injuring  any  important  structures.  If  suppuration  con- 
tinue, in  spite  of  free  drainage  and  careful  antiseptic  after-treatment, 
threatening  the  life  of  the  patient  from  exhaustion  or  sepsis,  more  ag- 
gressive measures  are  indicated.  Under  such  circumstances,  it  becomes 
often  an  exceedingly  difficult  matter  to  decide  which  one  of  the  operative 
procedures  should  be  adopted:  arthrectomy,  excision,  or  amputation.  If 
the  patient's  strength  is  so  much  reduced  that  arthrectomy  or  excision 
offer  no  prospects  of  a  successful  issue,  amputation  should  be  performed. 
This  alternative  becomes  an  unavoidable  necessity  if  the  suppurative  ar- 
thritis is  complicated  by  extensive  burrowing  of  pus  among  the  muscles, 
tendons,  and  paraarticular  tissues.  If  the  patient's  strength  warrant  an 
arthrectomy,  this  operation  should  be  done  if  the  disease  is  limited  to  the 
synovial  membrane  of  the  joint.  Typical  or  atypical  resection  is  to  be 
restricted  to  cases  where  the  articular  cartilages  and  bone  itself  are  found 
diseased.  In  resection  of  joints  for  suppurative  affections,  the  surgeon 
must  aim  to  remove  only  infected  tissues;  hence  incomplete  atypical  are 
more  frequently  indicated  than  complete,  or  typical,  resections.  All  cases 
of  suppurative  inflammation  of  joints  should  be  treated  from  the  be- 
ginning by  immobilization  of  the  limb  and  by  the  use  of  an  appropriate 
mechanical  support,  both  for  the  purpose  of  securing  rest  and  to  prevent 
deformities. 

ENDOCEANIAL  SUPPURATION". 

(a)  Suppurative  Pachymeningitis. — Suppurative  inflammation  of  the 
dura  mater  occurs  either  as  a  circumscribed  or  diffuse  affection.  It  is 
caused  by  direct  or  indirect  infection  with  pus-microbes.    Direct  infection 


316  PRINCIPLES    OF    SUEGERY. 

occurs  when  the  membrane  is  in  communication  with  an  infected  pene- 
trating wound  of  the  skull.  Traumatism,  without  infection,  never  results 
in  suppurative  inflammation  of  the  envelopes  of  the  brain;  nor  does  the 
presence  of  an  aseptic  foreign  body  produce  it.  Aseptic  injuries  of  the 
brain  and  its  envelopes  are  productive  of  circumscribed,  degenerative,  or 
plastic  lesions,  but  no  suppuration.  Septic  inflammation  of  the  meninges, 
on  the  other  hand,  is  noted  for  its  tendency  to  become  diffuse  and  to 
extend  from  one  tissue  to  another,  both  by  continuity  and  contiguity. 
Thus,  in  cases  of  pachymeningitis  with  loss  of  continuity  of  the  dura 
mater,  in  cases  of  compound  fractures  of  the  skull,  resulting  from  infec- 
tion with  23us-microbes  from  without,  the  inflammation  commences  upon 
the  outer  surface  of  the  membrane,  and  if  the  pus-microbes  do  not  pene- 
trate the  tissues  the  suppurative  process  remains  superficial;  but,  as  is 
more  frequently  the  case,  the  microbes  wander  deeper  into  the  tissues, 
until  the  entire  thickness  of  the  dura  has  become  infected,  and  when  the 
inner  surface  is  reached,  the  underlying  membranes,  the  arachnoid  and 
pia  mater,  as  well  as  the  surface  of  the  brain  itself,  are  liable  to  become 
involved,  step  by  step,  by  the  extension  of  the  infection  from  membrane 
to  membrane  and  surface  to  surface.  Suppurative  pachymeningitis  may 
remain  as  a  circumscribed  affection,  and,  if  the  internal  surface  of  the 
dura  is  the  seat  of  suppuration,  it  results  in  the  formation  of  a  subdural 
abscess.  In  circumscribed  subdural  suppuration  the  diffusion  of  the  pus 
between  the  dura  mater  and  the  arachnoid  is  prevented  by  a  plastic  exuda- 
tion, which  cements  the  two  membranes  together.  In  suppurative  pachy- 
meningitis, affecting  only  the  outer  surface  of  the  dura,  we  often  find  a 
subcranial  abscess,  the  outer  wall  of  which  is  formed  by  the  skull  and  the 
inner  by  the  dura  mater.  The  mechanical  effect  of  the  presence  of  pus  in 
either  locality  will  give  rise  to  the  same  group  of  cerebral  symptoms.  In- 
direct infection  of  the  dura  mater  with  pus-microbes  occurs  in  cases  of 
suppuration  in  the  epicranial  tissues  and  in  suppurative  osteomyelitis  of 
the  cranial  bones,  by  extension  of  the  infection  along  the  course  of  blood- 
vessels. In  this  way  an  insignificant  peripheral  suppurative  lesion  of  the 
coverings  of  the  skull  is  often  followed  by  a  grave  form  of  endocranial 
suppuration. 

Symptoms  and  Diagnosis. — Diffuse  septic  pachymeningitis  is  always 
attended  by  inflammation  of  the  arachnoid,  pia  mater,  and  cortex  of  the 
brain,  and  the  symptoms  point  more  toward  a  cortical  encephalitis  than 
a  pachymeningitis.  Localized  suppurative  pachymeningitis  gives  rise  to 
symptoms  which  indicate  the  presence  of  a  phlegmonous  inflammation, 
modified  in  this  instance  by  symptoms  arising  from  mechanical  disturb- 
ances, caused  by  the  presence  of  inflammatory  exudation,  or  the  partici- 
pation of  the  surface  of  the  brain  in  the  suppurative  process.    In  the  acute 


ENDOCEANIAL    SUPPURATION.  317 

septic  form,  following  a  compound  fracture  of  the  skull,  the  first  symp- 
toms are  observed,  usually,  during  the  second  or  third  day  after  the  in- 
jury, and  rapidly  increase  in  intensity  from  the  progressive  extension  of 
the  infection.  In  the  circumscribed  form  the  symptoms  are  more  localized. 
The  headache  is  often  severe,  especially  if  the  inflammation  is  located 
upon  the  inner  surface  of  an  intact  dura,  and  involves  a  corresponding 
extent  of  the  subjacent  membranes  and  cortex  of  the  brain.  The  early 
symptoms  are  those  of  irritation,  to  be  followed,  as  the  accumulation  of 
pus  increases,  by  evidences  of  compression.  By  means  of  focal  symptoms, 
it  is  often  possible  to  locate  the  seat  of  the  inflammatory  product  in  the 
interior  of  an  intact  skull  with  sufficient  accuracy  to  enable  the  surgeon 
to  evacuate  the  pus  by  operative  measures.  Acute  suppuration  between 
the  surface  of  the  brain  and  the  inner  surface  of  the  skull  is  always  at- 
tended by  a  rise  in  the  temperature.  The  pulse  is  accelerated,  at  first  full 
and  bounding,  to  become  slower  and  slower  as  compression  increases.  If 
the  pulse,  in  a  case  of  endocranial  inflammation,  has  been  gradually  re- 
duced from  120  to  35  or  40,  it  is  a  sign  that  cerebral  compression  has 
reached  the  maximum  extent  compatible  with  life,  and  when  it  again 
reaches  its  former  frequency  it  is  an  indication  that  dissolution  is  near  at 
hand.  The  condition  of  the  dura  mater  in  subdural  suppuration  is  of  great 
importance  in  determining  the  presence  or  absence  of  accumulation  of  pus. 
In  compound  fractures,  with  loss  of  bone-substance,  the  existence  of  a  sub- 
dural abscess  is  indicated  by  bulging  of  the  dura  into  the  opening  of  the 
skull  and  absence  of  cerebral  pulsations.  In  trephining  the  skull  for  a 
supposed  endocranial  abscess,  the  surgeon's  duty  is  to  explore  the  sub- 
dural space,  or  to  incise  the  dura  mater,  if  this  membrane  appear  tense  or 
bulge  into  the  opening,  and  if  cerebral  pulsations  cannot  be  seen  or  felt. 

Treatment. — The  successful  prevention  of  endocranial  infection  by 
rigid  antiseptic  precautions  in  compound  fractures  of  the  skull  and  endo- 
cranial operations  is  one  of  the  best  arguments  in  support  of  the  value  of 
the  antiseptic  treatment  of  wounds.  Intentional  opening  of  the  skull 
under  strict  aseptic  precautions  is  seldom  followed  by  suppurative  endo- 
cranial inflammation.  Compound  fractures  of  the  skull  without  fatal  in- 
jury to  the  brain,  if  treated  by  strict  antiseptic  measures  soon  after  the 
receipt  of  the  injury,  generally  result  in  recovery  of  the  patient.  The 
most  important  indication  in  the  treatment  of  these  cases  is  to  prevent 
infection  of  the  wound,  and  thus  guard  most  effectively  against  the  oc- 
currence of  endocranial  suppuration. 

In  the  treatment  of  compound  fractures  of  the  skull,  correction  of 
mechanical  difficulties  is  nothing  as  compared  with  the  importance  of 
carrying  out  full  antiseptic  precautions  to  prevent  the  fatal  complications. 
Suppurative  pachymeningitis  is  prevented  by  the  same  treatment  which 


318  PEINCIPLES    OF    SUEGEEY. 

secures  an  ideal  aseptic  healing  in  wounds  of  other  parts.  The  proph3dactic 
treatment  aims  at  obtaining  for  the  external  wound,  the  fractured  bones, 
and  the  exposed  spaces  underneath  them  a  perfectly  aseptic  condition. 
The  entire  head  should  be  shaved  and  the  scalp  rendered  aseptic  by  wash- 
ing it  with  warm  water  and  potash-soap,  to  be  followed  with  a  solution  of 
corrosive  sublimate  (1  to  1000),  and,  lastly,  with  sulphuric  ether  or  alco- 
hol. The  wound  of  the  pericranial  tissues  is  enlarged  sufficiently  to  ad- 
mit of  thorough  disinfection  of  the  crevices  between  the  fragments.  Blood- 
clots  and  other  foreign  substances  are  to  be  sought  for  and  removed,  as 
infection  is  often  traceable  to  imperfect  treatment  in  this  regard.  Loose 
fragments  are  removed  and  kept  in  a  warm  solution  of  corrosive  sublimate 
until  they  are  reimplanted.  Depressed  fragments  are  elevated,  and  the 
space  between  the  bone  and  the  dura  disinfected.  If  the  dura  has  been 
lacerated  the  disinfection  is  carried  further.  Detached  and  contused  brain- 
tissue  is  removed.  All  haemorrhage  is  carefully  arrested,  and  after  the  final 
irrigation  the  dura  is  sutured,  and,  if  necessary,  a  capillary  drain  of  aseptic 
catgut  or  horse-hair  inserted. 

In  the  majority  of  cases  it  is  advisable  to  drain  the  external  wound 
by  the  insertion  of  a  tubular  drain  at  the  most  dependent  point.  Eeten- 
tion  of  the  antiseptic  dressing  is  secured  best  by  applying  a  few  turns  of 
a  plaster-of-Paris  bandage.  If,  in  spite  of  thorough  primary  disinfection, 
asepsis  is  not  secured,  secondary  disinfection  is  to  be  instituted  at  once. 
This  requires  that  the  superficial  sutures  be  removed.  Detached  bone 
is  not  to  be  reimplanted  a  second  time,  for  fear  of  renewed  infection.  The 
whole  surface  is  now  disinfected  by  filling  every  sinus  and  depression  with 
peroxide  of  hydrogen.  After  efi:ervescence  has  ceased  the  fluid  is  washed 
away  by  irrigation  with  the  ordinary  antiseptic  solutions.  The  ,peroxide, 
of  hydrogen  will  reach  parts  of  the  infected  surface  inaccessible  to  other 
antiseptic  solutions.  If  any  evidences,  local  or  general,  point  to  the  ex- 
istence of  a  beginning  inflammation  of  the  dura  mater  and  the  subjacent 
membranes,  the  deepest  portions  of  the  wound  are  subjected  to  thorough 
disinfection,  and  tubular  subdural  drainage  is  established.  If  secondary 
disinfection  prove  unsuccessful  the  antiseptic  dressing  is  to  be  removed 
and  the  moist  antiseptic  compress  substituted,  which  is  removed  from  time 
to  time,  when  the  deeper  portions  of  the  wound  are  cleansed  by  irrigation 
with  an  antiseptic  solution. 

An  external  suppurative  pachymeningitis  is  treated  in  the  same  way  as 
an  infected  compound  fracture  of  the  skull.  If  it  follow  a  compound  fract- 
ure, loose,  detached  bones  are  removed,  and  the  whole  suppurating  surface 
is  disinfected;  after  which,  tubular  drainage  is  established.  If  it  follow  a 
flssured  fracture,  a  sufficiently  large  opening  is  made  in  the  skull  to  permit 
of  free  disinfection,  and  the  accumulation  of  pus  is  prevented  by  the  inser- 


ENDOCRANIAL    SUPPUEATION.  319 

tion  of  a  tubular  drain.  Suppuration  between  tlie  dura  mater  and  the  cranial 
vault  in  an  intact  skull  is  treated  by  making  one  or  more  openings  in  the 
skull  for  disinfection  and  drainage.  A  subdural  abscess  without  fracture  of 
the  skull  is  to  be  accurately  located  by  a  systematic  and  accurate  study  of  the 
clinical  history  of  the  case,  and  by  reference  to  the  etiology  of  the  suppura- 
tive process,  and  the  information  thus  obtained  can  usually  be  corroborated 
by  focal  symptoms  which  point  to  the  exact  location  of  the  disease.  The 
skull  is  opened  with  the  chisel  over  the  point  where  the  abscess  is  suspected. 
If  the  dura  bulge  into  the  opening,  is  tense,  and  the  pulsations  of  the  brain 
cannot  be  felt,  the  surgeon  may  be  almost  sure  that  a  subdural  abscess  is 
present,  and  confirms  his  suspicion  by  an  exploratory  puncture.  If  pus  is 
found,  the  dura  mater  is  incised,  the  cavity  washed  out  with  an  antiseptic 
solution,  and  a  tubular  drain  is  inserted.  A  daily  change  of  the  dressing  and 
washing  out  of  the  cavity  with  an  antiseptic  solution  are  necessary  until  sup- 
puration has  nearly  ceased;  then  the  dressing  is  removed  less  frequently, 
and  the  drain  is  shortened  as  the  cavity  diminishes  in  size.  If  at  the  point 
where  the  abscess  was  localized  the  dura  present  no  indications  of  subdural, 
intracranial  pressure,  but  the  surgeon  feels  sure  otherwise  of  his  diagnosis, 
it  is  justifiable  to  make  a  number  of  small  exploratory  punctures  until  he 
succeeds  in  locating  the  suppurating  focus.  If  the  abscess-cavity  is  large, 
and  the  first  opening  has  been  made  at  a  point  unfavorable  to  efficient  drain- 
age, it  is  advisable  to  imitate  the  example  of  Macewen,  to  make  a  counter- 
opening  in  the  skull  and  dura  at  the  most  dependent  point,  and  to  maintain 
through  drainage  until  suppuration  ceases.  A  localized  suppurative  pachy- 
meningitis, recognized  in  time,  and  located  with  sufficient  accuracy  to  admit 
of  radical  treatment  by  operative  measures,  is  an  affection  which  the  modern 
surgeon  treats  with  every  assurance  of  success. 

(b)  Suppurative  Leptomening-itis. — Inflammation  of  the  arachnoid, 
without  implication  of  the  pia  mater  and  surface  of  the  brain,  never  occurs, 
and  on  this  account  we  no  longer  speak  of  inflammation  of  any  of  these 
structures  as  separate  lesions,  but  substitute  the  term  Upt'Omeningitis,  by 
which  is  meant  inflammation  of  the  two  inner  envelopes  of  the  brain,  com- 
bined with  cortical  encephalitis.  The  surface  of  the  brain  is  supplied  in  part 
with  blood-vessels  from  the  pia  mater,  and  this  intimate  vascular  connection 
establishes  an  equally  intimate  pathological  relationship  between  these  two 
structures.  A  septic  leptomeningitis  is  a  diffuse  inflammation  of  the  arach- 
noid, pia  mater,  and  cortex  of  the  brain,  caused  by  infection  with  pus- 
microbes,  and  which,  in  the  absence  of  all  tendencies 'to  localization,  proves 
fatal  before  well-marked  suppuration  has  occurred.  Although  septic  inflam- 
mation of  the  meninges  of  the  brain  is  usually  caused  by  the  ordinary  pus- 
microbes,  cases  have  been  reported  in  which  the  streptococcus  of  erysipelas 
or  the  pneumococcus  was  found  as  the  sole  microbic  cause,  and  Scherer 


320  PRINCIPLES    OF    SURGERY. 

records  three  cases  of  acute  suppurative  leptomeningitis  due  to  the  colon 
bacillus.  The  patients  were  nurslings.  Etiologically  and  pathologically 
leptomeningitis  resembles  diffuse  septic  peritonitis.  Examination  of  the 
contents  of  the  skull  reveals  great  vascularity,  more  or  less  serous  transuda- 
tion, and  softening  of  the  gray  matter  of  the  brain.  Microscopical  examina- 
tion shows  only  a  moderate  emigration  of  the  colorless  corpuscles  and  the 
minute  changes  in  the  capillary  vessels,  which  are  characteristic  of  acute  sep- 
tic iiiflammation.  Suppurative  leptomeningitis  is  characterized  by  the  pres- 
ence of  pus  between  and  upon  the  membranes  and  upon  the  surface  of  the 
brain.  Septic  leptomeningitis  always  terminates  in  suppuration,  if  the  life 
of  the  patient  is  sufhciently  prolonged  for  emigration  of  leucocytes  and  their 
transformation  into  pus-corpuscles  to  occur.  Septic  leptomeningitis  some- 
times appears  within  a  few  hours  after  a  perforating  wound  of  the  skull. 
Bergmann  relates  the  case  of  a  child  where  a  convex  meningitis  could  be 
diagnosticated  four  hours  after  an  injury  of  the  skull.  Konig  reports  a  case 
that  came  under  his  observation  where  well-marked  symptoms  of  leptomen- 
ingitis followed  ten  hours  after  perforation  of  the  skull  with  the  point  of  a 
sword.  The  wound  was  examined  outside  of  the  hospital  with  instruments 
that  had  not  been  disinfected.  Ten  hours  after  the  injury  the  patient  com- 
menced vomiting,  and  had  a  temperature  of  39°  C.  The  following  day,  wild 
delirium,  strabismus  divergens,  and  a  temperature  of  40°  C.  The  second 
day,  coma,  rapid  pulse,  and  death.  The  necropsy  revealed  diffuse  septic  lep- 
tomeningitis. The  inflammatory  product  is  found  most  abundant  in  the  sub- 
arachnoid space.  The  effusion  in  this  space  is  sometimes  clear,  raising  the 
arachnoid;  it  contains,  also,  fibrin  in  flakes  and  membranes,  or  it  presents 
the  consistence  and  color  of  pus.  Pus  first  appears  along  the  course  of  blood- 
vessels in  the  pia  in  the  shape  of  yellow  streaks,  which,  when  they  become 
confluent,  tend  to  considerable  inflammatory  thickening  of  the  membrane. 
Pus  may  also  appear  in  the  ventricles  by  way  of  communication  with  the 
subarachnoidal  spaces.  On  account  of  the  absence  of  connective-tissue 
spaces,  the  inflammation  of  the  surface  of  the  brain  remains  superficial.  If 
pus  form  here,  it  appears  as  small  abscesses,  which  later  may  become  con- 
fluent, causing  superflcial  destruction  of  the  brain-substance.  If  the  surface 
of  the  brain  is  the  seat  of  a  contusion,  suppurative  encephalitis  is  more  dif- 
fuse, and  may  lead  to  a  diffuse  acute  abscess  underneath  the  infected  envel- 
opes. 

Besides  wounds  communicating  with  the  atmosphere  through  which 
infection  takes  place,  suppurative  leptomeningitis,  like  pachymeningitis,  can 
be  caused  by  peripheral  suppurative  lesions,  as  phlegmonous  inflammation 
of  the  soft  tissues  covering  the  skull,  suppurative  osteomyelitis  of  the  cranial 
bones,  and  suppurative  inflammation  of  the  middle  ear.  In  fractures  at  the 
base  of  the  skull,  infection  frequently  occurs  through  a  ruptured  tympanum. 


ENDOCEAXIAL    SUPPUEATIOX.  321 

or  tlirough  a  -wound  of  the  soft  parts  in  the  naso-pharj^nx  communicating 
directly  ^vith  the  meninges. 

Symptoms  and  Diagnosis.— The  surgeon  should  be  versed  in  the  symp- 
toniatolog}''  of  suppuratiye  leptomeningitis,  rather  for  the  purpose  of  know- 
ing when  not  to  interfere,  by  operative  procedure,  in  cases  of  endocranial 
suppurative  lesions,  than  to  risk  his  reputation  in  a  fruitless  attempt  in 
operating  for  an  incurable  disease.  Diffuse  septic  and  suppurative  leptomen- 
ingitis are  fatal  diseases,  and  the  surgical  treatment  will,  in  all  probability, 
always  remain  of  a  purely  prophylactic  character.  The  symptoms  of  lepto- 
meningitis are  always  those  of  cortical  encephalitis,  from  which  it  cannot  be 
distinguished  during  life.  The  disease  is  often  initiated  by  a  chill,  like 
phlegmonous  inflammation  in  other  localities,  followed  by  high  fever  and 
other  symptoms  of  septic  intoxication.  In  other  cases  the  chill  is  absent  and 
the  fever  develops  more  insidiously.  The  rise  of  temperature,  which  is  usu- 
ally abrupt, — the  thermometer  after  a  few^  hours  shows  an  increase  to  39°  or 
40°  C,  and,  as  a  rule,  presents  but  slight  variations, — is  caused  by  the  absorp- 
tion of  septic  material  from  the  infected  and  inflamed  tissues.  The  intra- 
cranial pressure  and  fever  give  rise  at  once  to  symptoms  which  indicate  the 
presence  of  cerebral  irritation.  Headache,  morbid  sensitiveness  to  external 
impressions,  sleeplessness,  restlessness,  and  psychical  perturbation  are  some 
of  the  most  constant  and  conspicuous  early  symptoms.  If  the  patient  fall 
into  a  short  nap  he  starts  up  suddenly  and  behaves  like  a  maniac.  The  pupils 
are  usually  contracted  at  first,  but  dilate  as  other  symptoms  of  compression 
appear.  Often  they  are  unequal  in  size  and  respond  only  sluggishly  to  light. 
Localized  and  general  convulsions  frequently  attend  the  stage  of  irritation. 
Vomiting  and  constipation  are  among  the  early  symptoms.  Paralysis  of 
definite  muscular  groups,  according  to  Bergmann,  indicates  extension  of  the 
disease  to  the  region  of  motor  centres.  The  face  is  sufEused,  the  conjunctiva 
injected,  and  the  pulsations  of  the  carotid  arteries  increased.  The  pulse,  at 
first  increased  in  frequency,  bounding  and  firm,  becomes  slower  as  cerebral 
compression  advances.  If,  after  its  frequency  has  been  reduced  to  40  or 
50  beats  per  minute,  it  again  becomes  rapid,  it  is  a  sure  indication  of  ap- 
proaching death. 

If  the  disease  develop  in  the  course  of  a  perforating  wound  of  the  skull, 
the  increased  intracranial  pressure  is  manifested  by  bulging  of  the  dura  mater 
into  the  wound,  or,  if  the  envelopes  of  the  brain  have  been  lacerated,  by 
hernia  of  the  brain.  The  prolapsed  portion  of  the  brain  often  sloughs,  when 
putrefaction  of  the  dead  tissue  occurs  as  an  u.navoidable  result,  and  death 
from  sepsis  is  hastened  by  such  an  occurrence.  Bergmann  has  called  the 
attention  of  the  profession  to  the  fact  that  leptomeningitis,  affecting  the 
convex  surface  of  the  brain,  leads  at  once  to  paralysis  of  one  extremit}',  or 
hemiplegia,  b}''  the  extension  of  the  disease  to  motor  centres.     Indications 


d^iJ  PEINCIPLES    OF    SUEGERY. 

pointing  to  localized  symptoms  of  central  irritation  can  be  explained  by  the 
same  theory.  Leptomeningitis  at  the  base  of  the  brain  is  not  attended  by  any 
definite  localized  focal  symptoms,  and  the  retraction  of  the  head  takes  place 
in  consequence  of  the  extension  of  the  inflammation  to  the  meninges  of  the 
spinal  cord.  Basilar  meningitis  in  its  advanced  stage  gives  rise  to  a  peculiar 
distnrbanoe  of  respiration:  the  Cheyne-Stokes  phenomenon.  With  the  ap- 
pearance of  compression  of  the  brain  the  symptoms  of  central  irritation  sub- 
side and  give  place  to  the  paralytic  stage.  The  patient  passes  from  a  con- 
dition of  listlessness  gradually  into  a  stupor,  and  finally  into  complete  coma. 
With  the  appearance  of  monoplegia  and  hemiplegia  some  centres  may  be  still 
in  a  condition  of  irritation,  so  that  sjauptoms  of  irritation  and  paralysis  may 
be  manifested  at  the  same  time.  During  the  paralytic  stage  the  sufEusion  of 
the  face  disappears,  the  face  is  pallid,  and  the  whole  surface  of  the  body  cov- 
ered with  a  clammy,  cold  perspiration;  the  pupils  dilate  and  no  longer  re- 
spond to  light;  the  pulse  becomes  small  and  rapid,  and  death  is  preceded  by 
relaxation  of  all  sphincter-muscles. 

Treatment.  —  The  prophylactic  treatment  has  for  its  object  the  pre- 
vention of  infection  through  wounds  communicating  with  the  contents  of 
the  skull.  Eigid  antiseptic  treatment  of  all  compound  fractures  of  the  skull 
must  be  carried  out  in  the  most  pedantic  manner.  Fractures  of  the  base  of 
the  skull,  communicating  with  the  atmospheric  air  through  a  ruptured  tym- 
panum or  through  a  lacerated  wound  in  the  naso-pharyngeal  region,  should 
be  treated  upon  the  same  principles  as  a  compound  fracture  of  the  vault  of 
the  cranium.  If  the  tympanum  has  been  ruptured  the  external  meatus  is 
thoroughly  disinfected  and  packed  loosely  with  iodoform  gauze,  over  which 
a  filter  of  salicylated  cotton  is  applied.  If  the  fracture  communicate  with  a 
wound  of  the  naso-pharyngeal  region,  disinfection  is  aimed  at  by  using  an 
antiseptic  nasal  douche  and  plugging  the  posterior  nares  with  tampons  of 
iodoform  gauze,  which  are  to  be  removed  daily,  and,  after  using  the  nasal 
douche,  are  to  be  replaced  by  new  ones.  The  prophjdactic  treatment  of  lepto- 
meningitis— caused  by  suppurating  foci  in  the  coverings  of  the  skull,  the 
middle  ear,  or  in  the  cranial  bones — can  be  carried  out  most  successfully  by 
early  and  rational  treatment  of  the  primary  diseases.  With  the  first  appear- 
ance of  the  symptoms  of  leptomeningitis,  the  surgeon  should  lose  no  time  in 
rendering  the  wound  or  primary  suppurating  depot  aseptic  by  operative 
measures,  combined  with  most  rigid  antiseptic  precautions,  with  a  faint  hope 
that  such  measures  may,  in  exceptional  cases  at  least,  lead  to  a  successful 
issue  by  limiting  the  extension  of  the  infection.  As  soon  as  the  disease  has 
become  diffuse  the  prospects  of  a  favorable  termination  are  almost  nil.  It 
may  be  possible  that  multiple  openings  in  the  skull,  with  subarachnoid  drain- 
age and  frequent  antiseptic  irrigations  or  permanent  irrigation,  will,  in  the 
future,  become  an  established  and  feasible  method  of  treatment  in  such 


BEAIX-ABSCESS.  o2o 

cases.  From  a  surgical  stand-point  sncli  heroic  treatment  appears  the  only 
rational  course  to  pursue  in  a  class  of  patients  otherwise  doomed  to  certain 
death.  The  multiple  perforations  would  have  a  potent  influence  in  dimin- 
ishing the  intracranial  pressure;  and  drainage,  combined  with  frequent  or 
permanent  irrigation,  might — at  least  in  a  small  percentage  of  cases— suc- 
ceed in  sterilizing  the  extensiye  area  of  infection. 

BEAIX-ABSCESS. 

The  term  abscess  of  the  train  should  be  limited  to  circumscribed  col- 
lections of  pus  surrounded  on  all  sides  by  brain-tissue.  Suppuration  occur- 
ring between  the  brain  and  its  envelopes,  from  a  circumscribed  suppurative 
leptomeningitis,  is  not  a  brain-abscess.  A  brain-abscess  is  the  result  of  a  cir- 
cumscribed suppurative  encephalitis.  The  acute  form  occurs  when  a  con- 
tused portion  of  the  brain  becomes  infected  through  a  wound  communicating 
with  the  atmospheric  air,  but,  as  this  form  will  seldom,  if  ever,  become  the 
subject  of  successful  operative  treatment,  our  remarks  will  apply  to  abscess 
of  the  brain  proper,  or  chronic  abscess.  A  chronic  circumscribed  encephalitis 
may  originate  in  a  contused  area  of  the  brain,  without  an}'  external  wound  or 
direct  route  of  infection,  from  localization  of  pus-microbes  in  the  locus 
m  inoris  resistentice.  Such  cases  have  been  frequently  observed  where,  weeks 
and  months  after  the  subsidence  of  the  symptoms  resulting  from  the  imme- 
diate effects  of  a  head  injury,  remote  s^anptoms  pointed  to  a  central  sup- 
purating focus  in  the  brain.  The  occurrence  of  such  grave  remote  conse- 
quences renders  the  prognosis,  even  after  slight  injuries  to  the  skull,  always 
more  or  less  doubtful.  In  other  instances  an  abscess  forms  around  a  foreign 
body  that  has  lodged  in  the  brain,  and  has  remained  for  a  long  time  without 
having  given  rise  to  any  local  or  general  disturbance.  Infected  penetrating 
wounds  of  the  skull  may  heal,  and  the  patient  apparently  recover  perfect 
health,  when  at  some  remote  time,  and  in  direct  causal  connection  with  the 
previous  infection,  a  chronic  abscess  develops,  perhaps,  some  distance  from 
the  primary  seat  of  infection.  Most  frequently  such  abscesses  are  caused  by 
suppurative  inflammation  of  the  middle  ear  and  suppurative  osteomyelitis 
of  the  cranial  bones.  In  size  they  vary  from  that  of  a  pea  to  that  of  an  entire 
hemisphere.  They  may  remain  stationary  for  twenty  years,  but  the  period 
of  latency  may  pass  into  activity  at  any  time.  A  large  abscess  in  the  white 
substance  of  a  hemisphere  may  give  rise  to  no  functional  disturbances  what- 
ever, and  can  only  be  recognized  by  the  terminal  symptoms.  In  other  cases 
the  abscess  cannot  only  be  diagnosticated  during  life,  but  its  location  ac- 
curately determined  by  s3'mptoms  which  point  to  destruction  of  a  particular 
part  of  the  brain. 

Symptoms  and  Diagnosis. — The  first  symptoms  are  insidious  in  their 
onset,  and  often  of  a  verv  indefinite  nature.    The  first  thins-  noticed  is.  fre- 


324  PEINCIPLES    OF    SUEGERY. 

quentl}^,  a  hypersensitiveness  and  irritable  temper  of  the  patient,  with  more 
or  less  severe  headache.  Early  loss  of  memory  is  often  noticed,  and  the  pa- 
tient becomes  dull,  sullen,  unconcerned,  and  reckless  inliis  business  trans- 
actions. If  the  abscess  involve  any  of  the  motor  centres,  or  a  considerable 
portion  of  fibres  originating  from  them,  monospasm  or  hemispasm,  or  mono- 
plegia or  hemiplegia,  follows  as  peripheral  evidence  of  the  central  lesion. 
General  convulsions,  which  sometimes  occur  at  this  stage,  have  less  diag- 
nostic value  than  localized  focal  symptoms.  Abscess  of  the  brain  seldom 
causes  fever;  on  the  other  hand,  the  temperature  is  often  subnormal.  A 
sudden  rise  in  temperature  indicates  that  the  abscess  has  reached  the  surface 
of  the  brain,  and  that  a  terminal  leptomeningitis  has  developed.  Eupture 
of  an  abscess  into  one  of  the  ventricles  is  followed  by  general  convulsions, 
paralysis,  and  death.  Prominence  of  the  dura  over  the  abscess  and  absence 
or  diminution  of  cerebral  pulsation  are  important  diagnostic  signs,  especially 
in  cases  where  the  abscess  is  located  near  the  surface  of  the  brain.  Examina- 
tion of  the  exposed  brain  by  palpation  may  elicit  evidences  of  deep-seated 
fluctuation.  In  exceptional  cases  the  portion  of  brain  covering  the  abscess 
is  firmer  than  normal  from  inflammatory  infiltration  (Eose). 

Gussenbauer  states  that  in  some  cases  the  presence  of  the  abscess  can 
be  ascertained  by  the  existence  of  fluctuation. 

Prognosis. — An  abscess  in  the  brain  is  always  an  imminent  source  of 
danger  to  life.  A  considerable  accumulation  of  pus  in  the  brain,  like  in  any 
other  organ,  is  never  removed  by  absorption.  If  the  abscess  remain  in  the 
active  stage  it  gradually  increases  in  size  until  it  ruptures  into  one  of  the 
ventricles  or  reaches  the  surface  of  the  brain,  in  either  event  resulting  in 
complications  which  lead  to  a  rapidl3'-fatal  termination.  It  may  remain  in 
a  latent  condition  for  an  indeflnite  period  of  time,  but  the  life  of  the  patient 
is  always  in  jeopardy,  as  acute  exacerbations  may  come  on  at  any  time.  If 
an  abscess  form  after  a  perforating  injury  of  the  skull,  and  the  pus  finds  an 
exit  through  a  permanent  fistulous  opening,  the  general  health  may  remain 
sufficiently  good  to  enable  the  patient  to  follow  his  occupation.  A  case  came 
recently  under  my  observation  where  I  could  introduce  the  probe  to  a  dis- 
tance of  four  inches  into  the  brain,  and  yet  the  general  health  remained  un- 
impaired, although  this  condition  had  existed  for  years.  The  brain-abscess 
in  this  case  developed  in  connection  with  purulent  inflammation  of  the  mid- 
dle ear.  I  have  knowledge  of  another  case,  where  a  young  man  received  a 
perforating  wound  of  the.  skull,  which  was  followed  by  the  formation  of  an 
abscess  of  the  brain  that  discharged  externally.  The  patient  fllled,  in  a  cred- 
itable manner,  a  responsible  and  important  government  position  for  thirty 
years,  and  died  from  another  cause.  The  necropsy  showed  an  abscess-cavity 
the  size  of  an  orange  located  in  the  anterior  right  lobe  of  the  brain,  which 
communicated  with  the  external  surface  through  a  fistulous  opening  in  the 


BEAIN-ABSCESS.  325 

skull.  A  few  cases  are  reported  where  recovery  followed  the  spontaneous 
discharge  of  the  contents  of  the  abscess  through  the  ear  or  nose,  but  ordi- 
narily such  an  occurrence  is  followed  by  putrefaction  of  the  remaining  con- 
tents of  the  abscess-cavity  and  death  from  sepsis. 

Treatment. — x4.ll  efforts  to  cure  an  abscess  of  the  brain  by  external  ap- 
plications or  internal  medication  will  be  worse  than  useless  in  effecting  re- 
moval of  the  pus  by  absorption.  All  expectant  treatment  is  unavailing. 
Brain-abscess  must  be  treated  on  the  same  principles  as  abscess  in  any  other 
organ:  by  incision  and  drainage.  The  great  difficulty  in  these  cases  is  to 
make  a  sufficiently  accurate  diagnosis  in  regard  to  the  exact  location  of  the 
abscess.  Before  anything  was  known  in  reference  to  the  subject  of  cerebral 
localizatiiDn,  Dupuytren  plunged  a  bistoury  deeply  into  the  brain,  and  was 
fortunate  enough  to  hit  an  abscess  which  he  suspected,  and  his  patient  re- 
covered. The  same  bold  treatment  has  been  frequently  followed  since,  but 
not  with  the  same  brilliant  result,  as,  in  the  majority  of  cases,  either  no  ab- 
scess existed  or  the  incision  was  made  not  into,  but  aside  of,  the  abscess. 
Localized  tubercular  lesions  of  the  brain  giving  rise  to  focal  symptoms,  re- 
sembling, in  this  respect,  tumors  or  abscesses,  are  of  frequent  occurrence, 
and,  if  they  can  be  recognized,  furnish  a  contraindication  to  surgical  inter- 
ference. Of  300  cases  of  brain-tumor,  reported  by  Starr  as  occurring  in  per- 
sons under  19  years  of  age,  152  were  tubercular.  Eight  of  the  20  cases  of 
tumor  of  the  brain  reported  by  Osier  were  tubercular.  Of  28  cases  that  came 
under  the  observation  of  Mills,  7  were  known  to  be  of  the  same  nature.  Eenz 
cured  an  abscess  of  the  brain  by  repeated  aspirations  through  a  fissure  in  the 
skull.  The  average  surgeon,  at  the  present  time,  would  not  undertake  to 
incise  a  brain  for  abscess  unless  he  had  previously  located  the  abscess  by  a 
careful  study  of  focal  symptoms  and  by  a  resort  to  exploratory  punctures 
(Fenger).  Bergmann  condemns  the  use  of  the  exploring-syringe  for  this 
purpose,  but  in  the  hands  of  those  less  skilled  in  cerebral  localization  than 
this  eminent  surgeon  the  exploring-needle  will  be  regarded  as  a  welcome 
and  useful  instrument  of  exact  diagnosis. 

Cerebral  Localization. — As  the  peripheral  symptoms  upon  which  the 
surgeon  relies  in  locating  an  abscess  in  the  brain  are  caused  by  irritation  or 
destruction  of  the  motor  tracts  or  centres,  it  is  absolutely  necessary  for  him 
to  become  familiar  with  the  topography  of  the  motor  centres.  A.  W.  Hare 
gives  a  very  practical  instruction  on  cerebral  localization  in  a  paper  published 
in  the  London  Lancet,  from  which  I  quote:  "In  the  parietal  region,  grouped 
around  the  fissure  of  Eolando,  are  the  areas  associated  with  movements  of 
the  extremities  of  the  opposite  side  of  the  body,  and,  at  the  lower  end  of 
the  fissure,  those  related  to  movements  of  the  mouth  and  tongue.  In  the 
accompanying  diagram  the  motor  areas  have  been  marked  in  their  anatomical 
relations  to  the  other  structures  of  a  normal  head,  dissected  for  the  purpose. 


326 


PRINCIPLES    OP    SURGEEY, 


showing  the  brain  in  its  natural  position.  The  areas  associated  with  move- 
ments in  neighboring  regions  of  the  body  have  been  shaded  alike  in  the 
figure.  Thus,  the  areas  A,  B,  C,  and  D,  bounding  the  fissure  of  Eolando 
posteriori}'-,  and  5  and  6,  in  front  of  the  fissure,  together  with  2,  3,  and  4,  at 
its  upper  end,  are  those  in  functional  connection  with  the  upper  extremity; 
A,  B,  C,  and  I)  being  concerned  in  the  movements  of  the  fingers,  head,  and 
wrist,  5  in  a  forward  movement  of  the  arm,  6  in  pronation  and  supination 
of  the  forearm,  and  2,  3,  and  4  in  coordinated  movements  of  the  whole  upper 
extremity.  The  areas  7,  8,  9,  10,  and  11,  indicated  as  having  a  common  re- 
gion of  motor  representation,  are  related  to  movements  of  the  tongue  and  of 
the  muscles  around  the  mouth.  Area  1  represents,  in  part,  movements  of 
the  loAver  extremity.  In  the  same  w^ay  areas  of  representation  of  general  and 
of  special  sensation  are  located  by  Ferxier  around  the  horizontal  limb  of  the 


Fig.  126.— Motor  Areas. 


fissure  of  Sylvius.  It  must  not  be  overlooked  that  this  mapping  out  of  areas 
has  an  absolute  exactitude  only  in  the  case  of  the  species  of  ape  upon  which 
the  experiments  were  performed.  Its  bearing  in  the  human  subject  is  one  of 
great  relative  importance,  but  it  must  not  be  looked  upon  as  a  final  statement 
of  fact,  in  the  case  of  man,  until  each  area  can  be  shoAvn  to  be  correctly 
placed,  as  it  is  by  the  accumulation  of  a  sufficient  number  of  clinical  and 
of  post-mortem  observations  directly  confirming  the  method  employed. 

"In  the  study  of  cranio-cerebral  topography  the  surgeon  has  to  rely  on 
four  primary  landmarks  in  establishing  a  system  of  measurements.  These 
are  the  glabella,  or  root  of  the  nose,  which  bears  a  definite  relation  to  the 
anterior  limit  of  the  cranial  cavity,  and  the  occipital  protuberance,  or  inion, 
which  bears  a  similar  relation  to  its  posterior  end,  corresponding  to  the  junc- 
tion of  the  falx  with  the  tentorium.  The  whole  mass  of  the  cerebrum  is  dis- 
posed between  these  two  points,  and  they  bear  definite  relations  to  its  cor- 


BRAIN-ABSCESS.  337 

tical  matter,  ■unmfluenced  by  the  structure  and  contour  of  the  bones  forming 
the  vault.  The  third  constant  landmark  is  the  external  angular  process  of 
the  frontal  bone,  which  bears  a  relation  to  the  lateral  expansion  of  the  frontal 
lobes,  similar  to  that  borne  by  the  two  prominences  already  mentioned,  to 
the  anterior  and  posterior  extremities  of  the  cerebrum.  It  has  also  a  uniform 
relation  to  the  fissure  of  Sylvius.  Lastly,  the  parietal  eminence  is  of  value, 
since  it  marks  the  greatest  lateral  expansion  of  the  substance  of  the  hemi- 
sphere, and,  as  Turner  has  shown,  bears  a  special  relation  to  the  submarginal 
convolution.  To  find  the  upper  end  of  the  fissure  of  Eolando  by  the  use  of 
these  data,  the  surface  measurement  in  the  middle  line  of  the  head  should 
be  taken  over  the  scalp  from  the  glabella  to  the  occipital  protuberance.  In 
ordinary  adult  heads  this  will  vary  from  11  to  13  inches;  measured  along 
this  line  from  before  backward,  the  distance  from  the  glabella  to  the  top  of 
the  fissure  will  be  55.7  per  cent,  of  the  total  distance  from  the  glabella  to  the 
occipital  protuberance.  The  following  scale  shows  the  distance  from  the 
glabella  to  the  top  of  the  fissu.re  in  all  ordinary  heads: — 

When  the  distance  from  the  glabella  to  the  The  distance  from  the  glabella  to  the  upper 
occipital  protuberance  is  end  of  the  fissure  of  Rolando  is 

U       inches.  6  Vio  inches. 

IIV2       "  6V5 

12  "  6V5 

12 1/2       "  7  " 

13  "  71/5 

"To  find  the  top  of  the  Eolandic  fissure.  Thane  halves  the  distance  from 
the  glabella  to  the  occipital  protuberance,  and,  having  thus  defined  the  mid- 
dle point  of  the  vertex,  takes  a  point  half  an  inch  behind  it  as  the  location 
of  the  upper  end  of  the  fissure.  Having  thus  ascertained  the  upper  end  of 
the  fissure,  it  is  desirable  to  determine  its  length  and  direction.  The  scalp 
measurement  corresponding  to  its  length  is  3  ^ f^  inches.  It  runs  from  above 
downward  and  forward,  its  axis  making  an  angle  of  67  degrees  with  the 
middle  line. 

"Wilson's  cyrtometer  is  an  exceedingly  useful  aid  in  locating  the  fissure 
of  Eolando.  It  consists  of  three  strips  of  flexible  metal  and  a  tape  for  secur- 
ing it  in  situ.    The  method  of  its  application  is  illustrated  by  Fig.  128. 

"The  broadest,  transverse  strip  passes  coronally  around  the  forehead, 
corresponding  with  the  glabella  and  external  angular  process;  the  narrower, 
longitudinal  strip  passes  backward  from  the  glabella  in  the  middle  line  to 
the  occiput.  This  strip  is  marked  with  two  scales  of  letters:  capitals  in  its 
posterior  fourth,  and  small  letters  about  the  middle  of  the  strip.  These  two 
scales  bear  a  relation  to  one  another  calculated  to  aid  in  the  application 
of  the  instrument  to  an  ordinary  head.  Measured  from  the  glabella  back- 
ward, the  distance  to  any  given  small  letter  is  55.7  per  cent,  of  the  distance 
from  the  glabella  to  the  corresponding  capital  letter;  thus,  when  any  capital 
letter  will  coincide  with  the  top  of  the  fissure,  a  third  narrow,  reversible  strip 


328 


PRINCIPLES    OP    SUEGERY. 


strikes  on  the  longitudinal  strip  of  metal,  marking  an  angle  of  67  degrees, 
opening  forward  and  marked  at  3  Y4  inches  from  its  attached  end,  thus  giv- 
ing the  length  and  direction  of  the  fissure  on  the  surface  of  the  head.  To 
determine  the  exact  location  and  direction  of  the  fissure,  a  line  is  drawn  from 
the  external  angular  process  of  the  frontal  bone  backward  to  the  occipital 
protuberance,  taking  the  shortest  route  between  these  points.  Such  a  line 
drops  a  little  toward  the  external  auditory  meatus,  avoiding  the  greater  con- 
vexity of  the  skull,  which  lies  in  the  course  of  a  horizontal  line  between  the 
bony  prominences.    It  usually  passes  about  ^/o  inch  above  the  meatus,  and 


Fig.  127. 


Fig.  128. 


Fig.  127.— Wilson's  Cyrtometer. 

Fig.  128. — Wilson's  Cyrtometer  Applied.    G,  glabella;  E  A  P,  external  angular  process;  R, 

fissure  of  Rolando,  its  position  and  direction  marked  by  the  lateral  strip  of  metal. 


thus  closely  corresponds  to  the  floor  of  the  middle  fossa,  and  behind  runs 
parallel  to  and  nearly  in  the  same  course  with  the  attachment  of  the  ten- 
torium and  the  posterior  half  of  the  lateral  sinus.  A  measurement  of  1  ^/g 
inches  along  this  line,  backward  from  the  external  angular  process,  marks 
the  lower  end  of  the  fissure  of  S5dvius.  From  this  point  a  straight  line  drawn 
to  the  centre  of  the  parietal  eminence  accurately  marks  the  course  of  the 
posterior  limb  of  the  fissure.  The  main  line  of  the  fissure  follows  the  line 
of  the  squamo-parietal  suture  to  its  highest  point,  whence  it  continues  its 
course  to  the  parietal  eminence.  The  middle  meningeal  artery,  after  groov- 
ing the  inner  surface  of  the  great  wing  of  the  sphenoid,  passes  on  to  the  ante- 


BEAIN-ABSCESS. 


339 


rior  angle  of  the  parietal  bone,  and  is  distributed  to  the  dura  mater  lining 
the  anterior  and  superior  half  of  the  bone.  If  the  surgeon  desire  to  expose 
the  tip  of  the  temporo-sphenoidal  lobe,  he  should  open  the  skull  behind  the 
upper  extremity  of  the  great  wing  of  the  sphenoid;  if  to  expose  Broca's  con- 
volution, immediately  in  front  of  the  same  bony  peninsula.  The  sites  of  the 
two  operations  are  shown  in  Fig.  129." 

Opening  of  the  Skull. — The  first  attempt  to  treat  a  brain-abscess  by 
direct  surgical  intervention  was  made  by  Morand  in  1751.  The  case  was  one 
in  which  the  abscess  communicated  with  the  surface  of  the  skin  by  a  fistulous 


o.p. 


Fig.  129. — Head,  Skull,  and  Cerebral  Fissures.  O.  P.,  occipital  protuberance; 
E  A  P,  external  angular  process;  S  F,  Sylvian  fissure;  A.  its  ascending  limb;  E.  R., 
fissure  of  Rolando;  P  E,  parietal  eminence;  M  M  A,  middle  meningeal  artery;  T  8, 
tip  of  temporo-sphenoidal  lobe;    B,  Broca's  convolution.     (Adapted  from  Marshall.) 


opening,  which  served  as  a  guide  in  applying  the  trephine,  and  the  fistulous 
tract  was  followed  in  approaching  the  abscess.  Le  Bond  reported  a  similar 
ease  in  1844.  Schede,  however,  was  the  first  to  propose  and  practice  trephin- 
ing of  the  intact  skull  in  the  treatment  of  brain-abscess  (1886).  The  opera- 
tive treatment  of  abscess  of  the  brain  presupposes  an  accurate  diagnosis  by 
means  of  cerebral  localization  and  a  careful  study  of  the  clinical  and  etio- 
logical aspects  of  the  case.  If  symptoms  of  abscess  of  the  brain  arise,  after 
a  compound  fracture  of  the  skull,  before  the  continuity  of  the  skull  has  been 
restored,  exploration  can  be  done  with  a  fine  needle  through  a  fissure,  or  at 
some  point  where  fragments  have  been  removed;    and,  if  pus  is  found,  a 


330  PEINCIPLES    OF    SUEGEEY. 

closed  li^emostatic  forcejDs  can  be  pushed  along  the  side  of  the  needle  into 
the  abscess,  and  the  track  enlarged  by  separating  the  blades  before  withdraw- 
ing the  instruments.  Into  this  track  a  drainage-tube  is  introduced,  the 
abscess-cavity  gently  irrigated,  and  the  wound  disinfected  and  dressed  anti- 
septically;  or,  a  small  quantity  of  peroxide  of  hydrogen  can  be  injected  into 
the  abscess-cavity  through  the  drainage-tube,  which  will  not  only  force  out 
the  contents,  but  will  also  sterilize  the  walls  of  the  abscess  more  thoroughly 
than  any  other  antiseptic.  If  an  abscess  develop  in  the  brain  in  an  intact 
skull,  or  after  the  fracture  has  healed,  the  skull  must  be  opened  at  a  point 
immediately  over  the  abscess.  By  means  of  the  measurements  given,  or  by 
the  use  of  Wilson's  cyrtometer,  the  motor  centre  or  centres  affected  by  the 
abscess  are  marked  upon  the  shaved  and  disinfected  scalp  before  the  skull  is 
exposed;  and  the  exact  location  of  the  abscess  is  also  marked  on  the  skull 
by  making  a  puncture  through  the  scalp  with  a  small  perforator,  so  that  the 
location  can  be  recognized  after  the  soft  parts  have  been  reflected.  The  bone 
is  laid  bare  at  this  point  by  Horsley's  flap,  which  is  made  by  a  horseshoe- 
shaped  incision,  the  convexity  of  which  is  directed  upward.  The  flap,  with 
the  periosteum  attached,  is  turned  downward.  After  all  haemorrhage  has 
been  arrested  the  skull  is  opened,  either  by  using  a  large  trephine  or,  what 
is  better,  with  a  chisel;  the  button  of  bone  or  bone-chips  are  transferred  into 
a  warm,  antiseptic  solution,  where  they  are  kept  until  needed  for  reimplanta- 
tion, should  this  be  deemed  necessary  or  advisable.  If  the  dura  mater  is 
tense  and.  bulge  into  the  opening,  and  cerebral  pulsations  are  feeble  or  en- 
tirely wanting,  the  indications  are  that  the  skull  has  been  opened  near  or 
directly  over  the  abscess.  The  opening  need  not  be  larger  than  an  inch  in 
diameter. 

Methodical  Exploration  of  the  Brain.  —  Experiments  and  clinical  ex- 
perience have  shown  that  the  brain  can  be  explored  in  different  directions 
with  a  fine,  hollow,  aseptic  needle  without  any  immediate  or  remote  bad 
effects  (Spitzka).  The  brain  should  never  be  incised  for  abscess  until  the 
abscess  has  been  located  by  methodical  exploration.  An  ordinary  exploring- 
syringe  Avith  a  delicate  needle  about  4  inches  in  length  should  be  used  for 
this  purpose.  The  needle  is  pushed  into  the  brain  in  the  direction  in  which 
the  abscess  is  suspected,  and  to  the  necessary  depth,  when  aspiration  is  made 
and  the  result  carefully  noted.  If  no  pus  is  found  the  needle  is  withdrawn  or 
pushed  forward  in  the  same  direction,  and  aspiration  made  at  different 
points  in  its  track;  and,  if  no  pus  is  found  in  that  direction,  it  is  withdrawn 
and  pushed  in  another  direction,  and  the  same  manoeuvres  repeated.  In 
this  manner  a  large  territory  can  be  explored  and  even  very  small  abscesses 
located.  When  the  abscess  has  been  located  by  thig  method  of  exploration, 
the  needle  is  used  as  a  guide  for  a  small  pair  of  haemostatic  forceps,  which  is 
pushed  forward  along  its  side  until  the  abscess  has  been  reached,  when  it  is 


BRAIX-ABSCESS.  331 

unlocked,  the  blades  slightly  sejoarated,  and  as  the  instrument  is  withdrawn 
the  track  is  sufficiently  enlarged  to  permit  the  insertion  of  a  rubber  drain 
the  size  of  an  ordinar}^  lead-pencil.  The  needle  is  only  removed  after  the 
drain  is  in  situ.  Fenger,  of  Chicago,  has  written  an  exceedingly  valuable 
paper  on  exploration  of  the  brain,  in  the  diagnosis  and  treatment  of  abscess 
of  the  brain,  in  which  he  has  furnished  abundant  proof  both  of  the  harmless- 
ness  and  utility  of  this  procedure. 

After  the  abscess  has  been  opened  and  drained,  it  is  advisable  to  wash 
it  out  gentl}^  with  some  non-irritating  and  yet  effective  antiseptic  solution, 
either  with  half  of  a  1-per-cent.  solution  of  acetate  of  aluminum  or  a  2-per-  - 
cent,  solution  of  boric  acid. 

As  the  abscess-walls  are  never  firm,  every  precaution  must  be  taken  to 
prevent  overdistension,  but  gentle  irrigation  is  continued  until  the  fluid  re- 
turns clear.  If  the  skull  has  been  opened  by  removing  a  disk  of  bone  by 
trephining,  an  opening  in  this  must  be  made  at  its  lower  margin,  which  will 
permit  bringing  the  drainage-tube  out  to  the  external  surface  after  implanta- 
tion. If  bone-chips  are  reimplanted,  a  space  for  the  drain  must  be  left  in  the 
most  dependent  portion  of  the  opening.  The  drainage-tube  is  brought  out 
at  one  of  the  lower  angles  of  the  wound  or  through  a  button-hole  in  the  flap. 
The  flap  is  secured  in  its  position  by  a  requisite  number  of  sutures.  Daily 
changes  of  dressing  is  required  until  suppuration  diminishes,  when  the  drain 
is  shortened  from  time  to  time  and  the  dressing  changed  less  frequently. 
The  drainage-tube  is  not  to  be  removed  until  the  abscess-cavity  is  closed,  as 
otherwise  a  relapse  Avould  be  liable  to  occur  which  would  require  a  repetition 
of  the  first  operation.  The  most  unsatisfactory  aspect  of  the  surgical  treat- 
ment of  abscess  of  the  brain  is  the  fact  that  in  some  instances  multiple  ab- 
scesses are  present:  an  occurrence  which  is  beyond  the  limits  of  the  present 
means  of  diagnosis.  In  such  cases  the  surgeon  may  cure  one  abscess,  but  the 
patient  succumbs  from  the  effect  of  those  that  have  not  been  discovered. 
The  appearance  of  a  hernia  cerebri,  after  the  evacuation  and  drainage  of  an 
abscess  of  the  brain,  is  a  condition  which  points  to  the  existence  of  an  addi- 
tional abscess  or  abscesses.  Should  such  a  condition  appear  during  the  after- 
treatment  of  an  abscess  of  the  brain,  treated  by  evacuation  and  drainage,  it 
would  furnish  a  strong  temptation  to  resort  to  another  methodical  explora- 
tion with  a  view  of  subjecting  additional  abscesses  to  the  same  radical  treat- 
ment. Should  the  first  opening  into  an  abscess  of  the  brain  not  be  suitable 
for  effective  drainage,  it  would  be  well  to  follow  the  example  of  Macewen  and 
open  the  skull  at  a  lower  point,  tunnel  the  intervening  portion  of  the  brain, 
between  this  opening  and  the  abscess-cavity,  with  hsemostatic  forceps,  and 
thus  establish  an  additional  and  more  efficient  route  for  drainage.  In  the 
surgical  treatment  of  abscess  following  suppurative  inflammation  of  the  mid- 
dle ear,  it  is  well  to  remember  that  in  these  cases  the  abscess  is  usually  located 


332  PEINCIPLES    OF    SUEGERY. 

in  the  vicinity  of  tlie  petrous  portion  of  the  temporal  bone,  and  that  in 
exploring  the  brain  the  needle  should  be  inserted  in  this  direction. 

EMPYEMA. 

Empyema  is  a  collection  of  pus  in  the  pleural  cavity.  It  is  always  the 
result  of  a  suppurative  pleuritis. 

Bacteriological  Studies. — A  penetrating  wound  of  the  pleural  cavity  is 
more  frequently  followed  by  infection  with  pus-microbes  and  suppurative 
pleuritis  than  perforation  of  one  of  the  bronchial  tubes,  as  in  the  latter  acci- 
dent the  atmospheric  air  entering  the  pleural  cavity  has  undergone  a  process 
of  filtration  during  its  passage  through  the  respiratory  tract.  Suppurative 
pleuritis,  occurring  without  direct  infection  through  a  perforation  in  the 
thoracic  wall  or  one  of  the  bronchial  tubes,  is  always  caused  by  localization 
of  pus-microbes  within  or  upon  the  serous  membrane  lining  the  pleural  cav- 
ity. Localization  of  pus-microbes  occurs  in  the  pleura  or  pleural  cavity 
either  as  a  primary  or  secondary  infection.  Frankel  made  a  bacteriological 
study  of  12  cases  of  empyema.  In  3  cases,  in  which  no  special  cause  could 
be  traced,  the  pus  contained  exclusively  the  streptococcus  pyogenes.  In  3 
cases  the  pus  contained  only  pneumococci.  Other  authors  have  found  in 
such  cases  also  other  pus-microbes.  Frankel  believes  that  when  this  is  the 
case  they  have  localized  in  consequence  of  a  secondary  invasion.  Charrin 
found,  in  the  pus  of  an  empyema  occurring  in  a  puerperal  woman,  pure  cult- 
ures of  the  proteus  vulgaris.  The  presence  of  streptococci  in  the  pus  from 
a  suppurating  pleural  cavity  presents  nothing  characteristic,  as  the  microbe 
is  also  found  in  cases  in  which  the  empyema  is  secondary  to  pneumonia  and 
tuberculosis.  On  the  other  hand,  he  assigns  to  the  pneumococcus,  in  pus 
taken  from  a  pleural  cavity,  a  diagnostic  significance,  as  it  proves,  beyond  all 
doubt,  that  the  suppurative  pleuritis  occurred  in  the  course  of  a  pneumonia 
as  a  secondary  affection;  consequently,  its  presence  in  the  pus  is  positive 
proof  that  a  pneumonia  exists  or  has  existed,  even  if  the  clinical  and  physical 
symptoms  were  not  sufficiently  clear  to  indicate  its  existence.  In  4  cases  the 
empyema  had  a  tubercular  origin,  in  2  of  which  pneumothorax  was  present 
at  the  same  time.  The  presence  of  the  bacillus  of  tuberculosis  in  the  pus  is 
not  easily  demonstrated,  but  the  absence  of  this  microbe  is  no  sign  that  the 
disease  is  not  tubercular,  as  inoculations  with  pus  in  animals  almost  con- 
stantly produce  typical  tuberculosis.  In  the  pus  of  tubercular  pyopneumo- 
thorax, if  microorganisms  are  present,  the  bacillus  of  tuberculosis  can  be 
found,  and  the  pus  shows  no  tendency  to  undergo  putrefactive  changes,  in 
contradistinction  to  empyema  occurring  in  non-tubercular  subjects,  in  whom 
spontaneous  discharge  through  the  bronchial  tubes  takes  place.  Senator 
maintains  that  putrefaction  is  prevented  by  the  parenchyma  of  the  lungs 
acting  as  a  filter,  preventing  ingress  of  bacteria  with  the  inspired  air,  and 


EMPYEMA.      '  333 

by  the  presence  of  a  large  amount  of  carbonic-acid  gas  in  the  air  of  the 
cavity,  as  it  is  well  known  that  microbes  do  not  thrive  so  well  in  such  an 
atmosphere  as  in  ordinary  air.  Ehrlich  has  made  an  interesting  bacterio- 
logical examination  of  the  pus  in  19  cases  of  empyema;  in  only  7  of  these 
could  the  bacillus  of  tuberculosis  be  found;  in  the  remaining  12  this  microbe 
could  not  be  detected,  and  upon  this  negative  ground  the  existence  of  tuber- 
culosis was  excluded.  Further  observation  in  these  cases  after  operation  cor- 
roborated the  diagnosis.  He  asserts,  therefore,  that,  in  the  purulent  pleu- 
ritic exudation  in  tubercular  patients  in  empyema  and  pyopneumothorax, 
the  presence  of  the  specific  microbic  cause  can  always  be  demonstrated.  This 
author  places  the  greatest  importance  on  a  bacteriological  examination  of 
the  pus  as  a  means  of  differential  diagnosis  between  suppurative  and  tuber- 
cular empyema.  A  serous  effusion  is  not  infrequently  transformed  into  an 
empyema  by  a  change  of  the  predominant  bacteriological  cause.  In  a  num- 
ber of  cases  I  found  it  necessary  to  aspirate  the  chest  for  the  removal  of  a 
copious  effusion.  The  fluid  removed  at  the  first  aspiration  was  clear  serum; 
the  second  aspiration  removed  a  slightly  turbid  fluid,  and  the  third  aspira- 
tion yielded  a  distinctly  sero-purulent  fluid;  while  the  fourth  aspiration  re- 
vealed a  well-marked  empyema.  In  all  of  these  cases  the  subsequent  history 
and  termination  showed  that  tuberculosis  was  the  primary  cause  of  the  ef- 
fusion. Infection  of  the  tubercular  foci  with  pus-microbes,  and  the  entrance 
of  these  into  a  cavity  already  changed  by  disease,  altered  the  type  of  the  in- 
flammation and  the  character  of  the  effusion.  Putrefaction  of  the  products 
of  suppurative  pleuritis  occurs  occasionally  without  the  presence  of  a  direct 
communication  of  the  pleural  cavity  with  the  atmospheric  air.  I  have  seen 
2  cases  of  this  kind,  and  both  recovered  after  radical  operation.  In  such 
instances  we  must  take  it  for  granted  that  saprophytic  bacilli  find  their  way 
into  the  pleural  cavity  through  the  respiratory  passages  and  the  parenchyma 
of  the  lungs,  and  select  the  products  of  coagulation-necrosis  for  their  nu- 
trient medium.  The  pus  in  such  cases  is  exceedingly  fetid,  thin,  and  usually 
contains  large  shreds  of  fibrin.  The  ptomaines  of  the  putrefactive  bacteria 
increase  the  fever  and  other  symptoms  of  septic  intoxication. 

Diagnosis. — The  presence  of  a  considerable  quantity  of  fluid  gives  rise 
to  well-marked  clinical  and  physical  symptoms.  Aside  from  the  ordinary 
symptoms  which  point  to  a  suppurative  inflammation  in  other  localities,  such 
as  chill,  fever,  pain,  loss  of  appetite,  the  patient  complains  of  difficulty  of 
breathing,  especially  on  lying  down,  and  sometimes,  but  not  always,  of  a 
short,  hacking  cough.  On  physical  examination  it  becomes  apparent  that  a 
part  or  nearly  the  entire  pleural  cavity  is  occupied  by  a  fluid.  Dullness  on 
percussion  and  absence  of  respiratory  and  voice  sounds  over  the  area  occu- 
pied by  the  fluid,  and  displacement  of  adjacent  organs  by  the  intrathoracic 
pressure  are  signs  which  cannot  be  well  simulated  by  anything  else  than 


33-i  PEINCIPLES    OF    SUEGEEY. 

accumulation  of  fluid  in  the  pleural  cavit3^  Bulging  of  intercostal  spaces^,  as 
a  rule,  is  more  marked  in  empyema  than  hydrothorax.  In  empyema  the  sub- 
cutaneous tissues  on  the  affected  side  are  often  slightly  03dematous  and  the 
superficial  veins  are  usually  enlarged.  In  empyema  of  the  right  pleural  cav- 
ity the  liver  is  pushed  in  a  downward  direction,  while  the  heart  is-  displaced 
toward  the  left  side.  In  empyema  of  the  left  side  the  apex-beat  of  the  heart 
can  quite  frequently  be  felt  on  the  right  side  of  the  sternum.  A  temperature 
of  100°  to  101°  F.  in  the  morning  and  101°  to  103°  F.  in  the  evening,  con- 
tinued for  several  weeks,  speaks  strongly  in  favor  of  empyema.  A  positive 
diagnosis  always  rests  on  demonstrating  the  presence  of  pus  in  the  pleural 
cavity,  which  can  be  done,  without  danger  and  without  pain  worth  mention- 
ing, by  an  exploratory  puncture  with  an  ordinary  hypodermic  needle.  In 
puncturing  the  chest  for  exploratory  or  therapeutic  purposes,  it  should  be 
borne  in  mind  that  the  needle  should  be  inserted  in  a  direction  which  corre- 
sponds to  the  centre  of  the  intercostal  space;  consequently  in  an  oblique 
direction  from  below  upward.  If  no  contraindications  present  themselves, 
the  exploratory  puncture  should  be  made  at  the  place  where,  later,  the  radical 
operation  will  be  performed;  that  is,  in  the  axillary  line,  between  the  sixth 
and  seventh  or  seventh  and  eighth  ribs.  If  the  needle  is  perfectly  aseptic 
no  harm  will  result,  even  should  the  lung  or  liver  be  punctured. 

Prognosis. — Simple,  uncomplicated  suppurative  pleuritis  offers  a  favor- 
able prognosis  if  subjected  to  early  radical  treatment.  The  prognosis  is  more 
favorable  in  children  than  in  adults,  and  in  recent  than  in  old  cases.  In  long- 
standing emp3^ema  the  lung  becomes  atelectatic  from  compression,  and  its 
full  expansion  is  also  prohibited  by  numerous  firm  adhesions.  In  children 
partial  expansion  of  the  lung  is  compensated  for  by  retraction  of  the  yielding 
chest -wall,  enabling  the  pleural  cavity  to  close;  while,  in  the  adult,  incom- 
ptete  expansion  of  the  lung  results  in  a  physical  condition  which  renders 
definitive  healing  a  difficult,  if  not  even  an  imj)ossible,  occurrence.  Ad- 
vanced pulmonary  tuberculosis  complicated  by  empyema  constitutes  a  con- 
traindication to  radical  operation,  as  the  patient  is  already  affected  by  a  dis- 
ease which  almost  necessarily  leads  to  a  fatal  issue,  and  a  radical  operation 
would  only  hasten  this  termination. 

A  fistulous  communication  between  a  bronchial  tube  and  the  pleural 
cavity,  resulting  from  a  rupture  of  an  empyema  in  this  direction,  in  excep- 
tional cases,  leads  to  a  spontaneous  cure,  but  more  frequently  becomes  a  cause 
of  retardation  of  recovery  after  an  operation. 

Treatment.- — An  empyema  is  nothing  more  nor  less  than  an  abscess  in 
the  pleural  cavity,  and  should  be  treated  as  such.  There  can  be  no  doubt  that 
in  exceptional  instances  a  cure  has  been  effected  by  aspiration.  This  method 
of  treatment  promises  more  in  children  than  in  adults,  and  it  is  also  in  the 
former  that  the  radical  operation  has  yielded  the  best  results;  hence  it  is  not 


EMPYEMA.  335 

advisable  to  have  recourse  to  an  uncertain  procedure  if  a  radical  operation 
aceomplisli  the  same  result  with  greater  certainty,  more  speedily,  and  with 
no  greater  immediate  and  remote  risks  to  life.  It  is  a  good  plan  in  every 
case  to  combine  aspiration  with  exploration,  for  the  purpose  of  improving  the 
conditions  for  a  radical  operation.  By  aspiration  we  demonstrate  the  pres- 
ence of  pus  in  the  pleural  cavity,  and,  by  removing  the  fluid  completely  or 
in  part,  we  aid  the  expansion  of  the  lung,  which,  by  the  time  the  radical  op- 
eration is  performed,  has  become  adherent  lower  down.  Aspiration  is  to  be 
followed,  in  the  course  of  two  or  three  da3^s,  by  a  radical  operation.  By  a 
radical  operation  we  understand  incision  of  the  pleural  cavity  and  draining 
the  same.  The  operation  for  empyema  by  incision  and  drainage  must  always 
be  done  under  the  strictest  aseptic  precautions,  as  any  mistake  or  negligence 
in  this  regard  is  exceedingly  liable  to  be  followed  by  infection  with  putre- 
factive bacteria:  an  occurrence  which  would  greatly  increase  the  danger  from 
sepsis.  Nothing  but  perfectly  aseptic  material  must  be  used,  and  the  whole 
chest  of  the  patient  and  the  hands  of  the  operator  must  be  thorou.ghly  dis- 
infected by  washing  with  hot  water  and  potash-soap,  and  disinfecting  with 
a  1-to-lOOO  solution  of  sublimate,  and  finally  with  alcohol.  The  instruments 
must  be  boiled  for  at  least  ten  minutes  in  a  1-per-cent.  soda  solution. 

(a)  Incision. — If  an  empyema  is  perforating  the  chest- wall  and  appears 
as  a  subcutaneous  abscess,  the  incision  is  made  through  the  centre  of  the 
abscess  and  parallel  to  the  ribs.  If  no  such  indication  is  present,  the  incision 
should  be  made  over  the  centre  of  the  sixth  rib  and  parallel  to  it  on  the  right 
side,  and  over  the  seventh  on  the  left,  at  a  point  corresponding  with  the 
axillary  line.  It  must  be  about  4  inches  in  length  and  extend  down  to  the 
bone. 

(b)  Resection  of  Eib.  —  The  soft  parts,  with  the  periosteum,  are  re- 
flected v/ith  an  elevator,  which  is  then  passed  between  the  periosteum  and 
rib,  posteriorly,  from  below  upward,  and  the  periosteum  separated  to  the  ex- 
tent of  1  V2  inches.  If  the  elevator  is  kept  in  close  contact  with  the  bone, 
there  is  no  danger  of  injuring  the  intercostal  vessels  or  nerves,  nor  of  open- 
ing the  pleural  cavity  prematurely.  With  the  elevator  the  rib  is  raised,  and 
a  section  1  ^/o  inches  in  length  is  removed  with  a  pair  of  heavy  bone-forceps. 
After  the  removal  of  the  bone  all  hsemorrhage  is  carefully  checked.  If  the 
pleura  feel  tense  and  bulge  into  the  wound,  there  is  no  necessity  of  making 
another  exploratory  puncture.  If  this  is  not  the  case,  as  a  matter  of  precau- 
tion, another  puneture^can  be  made,  at  this  stage  of  the  operation,  to  satisfy 
the  surgeon  of  the  presence  of  pus  imderneath.  The  incision  into  the  pleura 
is  then  made  with  a  bistoury,  in  the  centre  of  the  periosteal  gutter,  through 
this  membrane  and  the  pleura,  into  the  cavity  of  the  chest.  This  incision 
must  be  large  enough  to  allow  the  insertion  of  two  drainage-tubes  the  size  of 
the  little  finger.    The  deep  incision  in  the  soft  parts  can  be  readily  dilated 


336  PRINCIPLES    OF    SUEGEEY. 

to  the  requisite  extent  by  the  insertion  of  the  index  finger,  which  may  also 
be  used  in  interrupting  the  flow. 

(c)  Evacuation  of  Pus  and  Removal  of  Membranes. — A  great  deal  of 
information  is  gained,  as  soon  as  the  incision  into  the  chest  has  been  made, 
in  reference  to  the  expansibility  of  the  lung.  If  this  has  not  been  much  im- 
paired, the  pus  will  continue  to  escape  with  much  force,  especially  during 
inspiration.  Eapid  evacuation  is  attended  by  some  danger,  from  overdis- 
tension of  the  heart  and  vessels  in  the  lung,  and  must  be  guarded  against  by 
interrupting  the  flow,  from  time  to  time,  by  inserting  the  index  finger  into 
the  opening.  If  the  lung  expand  promptly,  its  lower  margin  can  often  be 
seen  through  the  opening  toward  the  end  of  evacuation.  The  more  the  lung 
expands,  the  less  the  amount  of  air  rushing  through  the  opening  into  the 
chest.  In  order  to  prevent  syncope  upon  the  sudden  diminution  of  intra- 
thoracic pressure,  during  evacuation  of  the  pus,  I  have  been  in  the  habit  of 
administering,  before  the  angesthetic  is  given,  ^/^oo  grain  of  atropia  with  ^/g 
grain  of  morphia,  hypodermically,  with  an  alcoholic  stimulant,  by  the  stom- 
ach or  rectum.  In  cases  of  empyema  with  a  bronchial  fistula,  and  in  cases 
where  respiration  was  so  much  embarrassed  that  I  deemed  the  administration 
of  an  anaesthetic 'hazardous,  I  have  repeatedly  made  the  radical  operation 
without  narcosis,  and  the  remedies  which  have  just  been  mentioned  answered 
an  excellent  purpose  in  diminishing  the  pain.  If,  as  is  so  often  the  case,  the 
pleura  is  lined  with  thick,  partially-detached  membranes,  these  should  be 
removed  with  a  dull  curette,  as  they  are  invariably  infected  with  pus-mi- 
crobes, and  their  presence  in  the  pleural  cavity  would  prolong  the  infection 
and  retard  recovery. 

(d)  Irrigation. — Irrigation  of  the  pleural  cavity  immediately  after  the 
operation  is  positively  contraindicated  if  a  bronchial  fistula  is  present,  and  it 
is  superfluous  if  no  putrefaction  is  present.  In  fetid  empyema  the  cavity  is 
washed  out  with  warm,  salicylated  water  until  the  fluid  returns  clear.  ISTone 
of  this  solution  should  be  allowed  to  remain  in  the  pleural  cavity. 

(e)  Drainage. — Eib  resection  should  always  be  done  in  operations  for 
empyema,  as  the  space  thus  created  offers  ample  room  for  the  insertion  of  a 
large  drain.  I  have  frequently  seen,  after  incision  and  drainage  through  an 
intercostal  space,  circumscribed  destructive  processes  of  the  margins  of  both 
ribs  from  pressure  caused  by  the  drainage-tube.  Such  pressure  is  not  only 
a  source  of  pain,  but  interferes  also  with  free  drainage.  Besection  of  such  a 
small  portion  of  a  rib  does  not  add  to  the  gravity  of  the  operation,  and  is  of 
the  greatest  utility  in  the  subsequent  management  of  the  case.  The  best 
drain  is  a  fenestrated  rubber  tube  the  size  of  the  little  finger,  or  two  rubber 
tubes,  somewhat  smaller,  stitched  together.  The  tube  should  be  from  4  to 
6  inches  in  length,  and  always  secured  externally  with  a  large  safety-pin,  to 
prevent  its  slipping  into  the  pleural  cavity.     IsTon-observance  of  this  little 


EMPYEMA.  337 

precaution  has  resulted  in  a  great  deal  of  trouble  from  drains  becoming  lost 
in  the  pleural  cavity.  The  necessity  of  making  a  counter-opening  and  of 
establishing  through  drainage  does  not  arise  often,  but,  when  such  a  pro- 
cedure becomes  necessary,  it  can  readily  be  done  with  a  large  Pean  forceps, 
which  can  be  introduced  into  the  anterior  opening,  and,  by  pushing  it 
through  the  intercostal  space  behind,  which  has  been  selected  for  the  coun- 
ter-opening, an  incision  is  made  down  upon  its  point,  after  which  the 
opening  is  dilated  and  a  long  drain  drawn  through  both  openings.  After 
completion  of  the  operation  a  large  antiseptic  dressing  is  applied. 

After-treatment. — Daily  change  of  the  dressing  and  antiseptic  irriga- 
tion will  be  necessary  in  fetid  empyema,  if  the  primary  disinfection  has  not 
proved  successful,  in  rendering  the  cavity  free  from  putrefactive  bacteria  and 
necrosed  material.  In  ordinary  cases  the  dressing  is  not  removed  until  it 
becomes  saturated  with  the  discharges,  or  if  the  temperature  indicate  the 
retention  of  septic  material.  Should,  at  any  time,  evidences  of  putrefaction 
or  sepsis  develop,  antiseptic  irrigations  are  positively  indicated.  A  saturated 
solution  of  acetate  of  aluminum,  an  aqueous  solution  of  tincture  of  iodine, 
a  3-per-cent.  solution  of  boric  acid,  Thiersch's  solution,  or  salicylated  water 
can  be  used  for  this  purpose,  always  using  the  solutions  at  blood-heat,  as  the 
irrigation  of  the  pleural  cavity  with  a  cold  or  cool  solution  has,  in  a  number 
of  cases,  resulted  in  death  from  shock.  In  one  of  my  cases  the  wife  of  the 
patient  irrigated  the  pleural  cavity  with  what  she  afterward  called  a  cool 
solution,  and  the  patient  died  suddenly  with  symptoms  of  collapse.  In  an- 
other case,  a  patient  5  years  of  age,  I  made  the  irrigation  myself,  using  only 
water,  the  temperature,  as  I  afterward  ascertained,  being  below  blood-heat, 
when  the  patient  suddenly  became  pulseless  and  the  respiration  ceased. 
Artificial  respiration  had  to  be  continued  for  a  considerable  length  of  time, 
when,  to  my  great  relief,  the  child  commenced  to  breath  spontaneously  and 
the  pulse  and  color  of  the  face  returned.  This  experience  warned  me  to  ex- 
ercise care  in  using  solutions  of  a  proper  temperature  in  irrigations  of  the 
pleural  cavity.  The  final  expansion  of  the  lung  and  obliteration  of  the  pleu- 
ral cavity  are  accomplished  by  the  granulating  process.  The  drain  should  be 
disinfected  every  time,  and  before  it  is  reinserted  it  should  be  dusted  with 
iodoform. 

(a)  Multiple  Resection  of  Ribs. — In  cases  of  empyema  where,  after  a 
radical  operation,  only  partial  expansion  of  the  lung  takes  place,  and  the 
pleural  cavity  cannot  close  on  account  of  the  unyielding  nature  of  the  chest- 
wall,  Estlander's  operation  of  multiple  resection  of  ribs  is  indicated.  The 
operation  consists  in  removing  sections  of  3  to  6  centimetres  in  length  of  all 
the  ribs  over  the  abscess-cavity,  for  the  purpose  of  allowing  the  chest-wall  to 
sink  in,  and  thus  remove  the  mechanical  obstacle  to  closure  of  the  pleural 
cavity.     Through  one  incision  over  an  intercostal  space  2  adjacent  ribs  can 


338  PEINCIPLES    OF    SURGERY. 

Tbe  removed.  If  more  than  2  ribs  have  to  be  resected,  I  prefer  to  make  a 
single  incision  in  the  direction  of  the  axillary  line,  through  which,  after  dis- 
secting back  the  superficial  soft  parts  for  1  or  3  inches  on  each  side  of  the 
incision,  6  or  8  ribs  can  be  readily  resected.  Estlander's  operation  is  abso- 
lutely valueless  in  cases  where  the  lung  is  almost  completely  collapsed,  where 
the  pleura  has  become  much  thickened  and  unyielding,  as  in  such  instances 
■even  the  most  extensive  resection  of  ribs  would  fail  in  correcting  the  me- 
chanical ditheulty  in  the  way  of  a  definite  healing  of  the  pleural  abscess. 
The  operation  is  also  contraindicated  where  farther  expansion  of  the  lung 
depends  on  incurable  lesions  of  that  organ. 

(b)  Thoracoplastic  Operation. — In  obstinate  cases  of  empyema,  where 
even  Estlander's  0|)eration  fails  in  effecting  a  cure,  and  where  the  difficulties 
in  the  way  are  of  a  purely  mechanical  nature,  Schede  has  described  a  pro- 
cedure which,  in  reality,  is  a  plastic  operation.  He  not  only  makes  resection 
of  several  ribs,  but  resects  the  entire  thoracic  wall  over  the  cavit}^,  with  the  ex- 
clusion of  the  skin.  He  makes  a  skin-flap  with  its  base  directed  upward,  cor- 
responding in  size  to  the  cavity  underneath,  and  then  removes  all  of  the  ribs 
in  the  region  to  the  same  extent,  and  finally  resects  the  remaining  portion  of 
the  chest-wall.  This  operation  exposes  one  side  of  the  cavity  completely, 
and  the  opposite  wall  is  then  covered  with  the  skin-flap.  The  flap  is  not 
sutured,  but  kept  in  place  by  a  compress  of  loose  gauze  corresponding  in  size 
and  shape  to  the  abscess-cavity.  This  operation  deals  more  effectually  with 
the  mechanical  difficulties  resulting  from  imperfect  expansion  of  the  lung 
than  Estlander's  multiple  resection  of  ribs,  and  will  always  be  resorted  to  in 
proper  cases  where  less  heroic  measures  have  failed  in  accomplishing  the  de- 
sired result. 

LUNG-ABSCESS. 

The  successful  treatment  of  abscess  of  the  lung  by  operative  procedure 
is  one  of  the  many  achievements  of  modern  surgery.  Bull,  of  Norway,  has 
collected  26  cases  of  abscess  of  the  lung  treated  by  incision  and  drainage,  of 
which  number  4  were  cured,  6  improved,  9  relieved,  and  7  were  not  benefited 
by  the  operation.  Abscess  of  the  lung  is  the  result  of  a  circumscribed  sup- 
purative inflammation  of  lung-tissue,  or  it  develops  after  an  attack  of  pneu- 
monia or  gangrene  of  the  lung.  If  it  follow  pneumonia,  a  part  of  the  solid- 
ified organ  fails  to  undergo  resolution  and  becomes  the  seat  of  secondary 
infection  with  pus-microbes.  The  abscess  then  forms  by  liquefaction  of  the 
inflammatory  product,  the  same  as  in  other  tissues.  Gangrene  of  the  lung 
can  only  take  place  if  the  tissues  are  destroyed  by  the  intensity  of  the  pri- 
mary infection  or  if  they  become  later  the  seat  of  secondary  infection  with 
putrefactive  bacteria  through  the  respiratory  passages.  If  the  gangrenous 
portion  is  limited  in  extent,  and  life  is  prolonged  for  a  sufficient  length  of 


LUNG-ABSCESS.  339 

time,  the  dead  tissue  becomes  detached,  and  is  frequently  eliminated  in  frag- 
ments through  a  bronchial  fistula  by  coughing.  The  cavity  which  is  formed 
in  this  manner  suppurates,  and  is  etiologically  and  clinically  an  abscess.  A 
circumscribed  suppurative  pneumonia,  resulting  in  the  formation  of  an  ab- 
scess, may  occur  around  a  foreign  body  which  has  lodged  in  one  of  the  bron- 
chial tubes.  The  clinical  history  of  every  abscess  of  the  lung  points  to  an 
antecedent  suppurative  pulmonary  inflammation,  with  or  without  gangrene. 

Diagnosis. — The  surgeon  diagnosticates  the  existence  and  location  of 
an  abscess  in  the  lung  by  the  same  methods  and  means  as  when  it  is  located 
in  another  organ.  If,  from  the  clinical  history  and  physical  examination  of 
the  chest,  he  has  reason  to  suspect  that  the  cavity  is  of  a  non-tubercular 
nature,  he  locates  it  as  accurately  as  he  can  by  the  physical  signs  which  are 
presented,  and  then  demonstrates,  ad  oculum,  the  existence  of  a  pus-cavity 
by  exploring  the  lung  with  the  needle  of  an  exploring-syringe.  Fenger  was 
the  first  one  in  this  country  to  locate  an  abscess  of  the  lung  by  this  means 
of  examination,  and  to  adopt  treatment  upon  strict  aseptic  surgical  prin- 
ciples. Microscopical  examination  of  the  sputum  is  of  great  value  in  de- 
termining whether  an  abscess  is  tubercular  or  the  result  of  a  suppurative 
inflammation. 

Methodical  Exploration  of  Lung  for  Abscess. — If  the  physical  symptoms 
point  to  a  non-tubercular  abscess  in  the  lung,  with  or  without  a  bronchial 
fistula,  the  surgeon  will  be  able  to  determine  the  portion  of  lung  involved 
by  ascertaining  over  the  abscess  a  limited  area  of  dullness  caused  by  con- 
densation of  lung-tissue  around  the  abscess,  and,  if  the  abscess-cavity  is  filled 
by  pus,  by  the  presence  of  this  fluid.  If  a  bronchial  fistula  exist,  ausculta- 
tion will  reveal  the  usual  symptoms,  caused  by  a  cavity  in  the  lung  partially 
filled  with  fluid.  By  means  of  percussion  and  auscultation  it  is  ascertained 
where  the  abscess  is  nearest  the  surface,  and  at  this  point  the  lung  is  explored 
with  a  hollow  needle,  not  exceeding  in  diameter  an  ordinary  knitting-needle, 
and  at  least  4  inches  in  length,  attached  to  a  hypodermic  or  exploring- 
syringe.  As  a  matter  of  course,  the  needle  and  surface  must  be  ren- 
dered perfectly  aseptic  before  the  puncture  is  made.  The  needle  is  pushed 
through  an  intercostal  space,  corresponding  to  the  location  of  the  disease, 
in  the  direction  of  the  centre  of  the  inflammatory  focus;  its  entrance  into 
the  abscess-cavity  is  attended  by  a  sudden  loss  of  resistance.  Aspiration  is 
now  made,  and  if  pus  is  found  the  diagnosis  is  made.  If  no  pus  is  withdrawn 
the  needle  is  pushed  forward,  and  at  different  points  aspiration  is  made.  If 
pus  is  not  found  in  one  direction,  the  needle  is  partly  withdrawn  and  pushed 
in  another  direction,  and  this  and  additional  tracks  are  explored  in  the  same 
manner  until  the  cavity  is  located.  An  abscess-cavity  only  partially  filled 
with  pus  may  be  entered  at  several  points  without  finding  pus.  If  the  sur- 
geon feel  sure  that  the  needle  is  in  a  cavity,  it  might  be  well  to  make  aspira- 


340  PEINOIPLES    OF    SUEGEKY. 

tion  with  the  patient  in  different  positions,  so  as  to  bring  the  pus  in  con- 
tact with  the  needle;  or,  if  this  fail,  to  inject  a  mild  antiseptic  solution 
through  the  needle,  which  will  be  coughed  up  if  the  injection  reach  the  cav- 
ity. No  operation  on  the  lung  must  he  undertaken  for  abscess  until  the  exact 
location  of  the  abscess  has  been  demonstrated  by  exploratory  puncture. 

Operation. — The  first  steps  of  an  operation  for  abscess  of  the  lung  are 
the  same  as  in  radical  operations  for  empyema.  At  least  a  section  of  one  rib 
is  removed.  With  few  exceptions,  the  lung  will  have  become  adherent  to  the 
parietal  pleura  at  the  time  the  operation  is  undertaken,  but  if  this  is  not  the 
case  it  will  become  necessary  to  leave  the  operation  unfinished  rather  than 
to  risk  an  onset  of  suppurative  pleuritis  after  the  lung-abscess  has  been 
opened.  In  such  a  case,  after  the  parietal  pleura  has  been  incised,  the  wound 
should  be  tamponed  with  iodoform  gauze,  and  the  opening  of  the  abscess 
postponed  until  adhesions  have  formed.  If  adhesions  make  it  safe  to 
complete  the  operation,  the  abscess  is  again  accurately  located  by  exploring 
with  a  needle,  and,  while  the  needle  is  in  the  cavity,  the  lung  is  incised  with 
the  knife-point  of  Paquelin's  cautery,  using  the  needle  for  a  guide.  By  mak- 
ing the  incision  with  the  actual  cautery  troublesome  parenchymatous  hgemor- 
rhage  is  avoided,  and  at  the  same  time  the  intervening  lung-tissue  is  pro- 
tected against  infection  by  a  tubular  eschar;  and  last,  but  not  least,  such  an 
opening  is  better  adapted  for  subsequent  free  and  effective  drainage.  A  rub- 
ber drain,  as  large  as  the  track  made  by  the  cautery,  is  inserted  into  the  cav- 
ity. If  the  abscess  communicate  with  the  bronchial  tubes  irrigation  cannot 
be  practiced;  if  this  is  not  the  case  the  abscess  is  disinfected  by  irrigation 
with  an  antiseptic  solution.  In  either  case  iodoformization  of  the  abscess- 
cavity  by  dusting  the  drain  with  iodoform  should  always  be  done.  If  the  first 
■opening  fail  to  drain  the  abscess  satisfactorily,  it  may  become  necessary  to 
make  a  counter-opening  at  the  most  dependent  part  of  the  cavity  and  estab- 
lish another  and  more  efficient  point  for  drainage  (Vogt-Mosler). 

The  after-treatment  in  cases  of  lung-abscess  treated  by  incision  and 
drainage  is  the  same  as  after  radical  operations  for  empyema. 

.^  SUPPURATIVE    PEEICAEDITIS. 

A  suppurative  inflammation  of  the  internal  surface  of  the  pericardium 
results  in  an  abscess  of  the  pericardium,  or  empyema  pericardii.  The  disease 
is  characterized  by  clinical  evidences  which  indicate  the  presence  of  a  sup- 
purative inflammation  and  by  physical  signs  which  point  to  the  presence  of 
fluid  in  the  pericardial  sac.  In  some  of  the  cases  which  have  been  reported 
it  was  attended  by  little  general  disturbance,  no  chill,  and  but  little  rise  of 
temperature.  If  it  occur  as  a  complication  of  some  other  affections,  the 
symptoms  of  the  latter  often  obscure  almost  completely  those  of  the  former. 
In  some  of  the  cases  the  presence  of  pus  was  indicated  by  oedema  in  the  prse- 


SUPPUEATIVE    PEEICAEDITIS.  341 

cordial  region.  If  the  quantity  of  pus  is  large,  the  pericardium  is  distended 
and  the  intercostal  spaces  in  front  of  the  effusion  are  more  prominent  than 
on  the  opposite  side.  The  area  of  dullness,  which  can  be  mapped  out  accu- 
rately by  percussion,  corresponds  with  the  size  of  the  expanded  pericardium. 
The  impulse  of  the  heart  is  felt  less  distinctly  and  is  more  diffuse  than  in  a 
normal  condition.  A  copious  pericardial  effusion  always  gives  rise  to  orthop- 
noea.  Positive  proof  of  the  existence  of  a  collection  of  pus  in  the  peri- 
cardium can  only  be  obtained  by  an  exploratory  puncture. 

Puncture  and  Aspiration  of  Pericardium. — Puncture  and  aspiration  of 
fluid  from  the  pericardium  is  a  comparatively  harmless  procedure,  if  it  is 
practiced  with  ordinary  skill  and  care. 

West  reports  79  cases  of  paracentesis  pe-ricardii.  Of  this  number,  the 
operation  was  the  cause  of  death  in  1  case  only,  and  in  this  instance  the  trocar 
which  was  used  perforated  the  right  ventricle.  Six  of  the  cases  died  during 
the  first  twenty-four  hours,  while  in  the  remaining  cases  the  immediate  effect 
of  the  operation  was  beneficial,  and  a  number  of  cases  recovered  permanently. 
In  puncture  of  the  pericardium  for  diagnostic  or  therapeutic  purposes,  the 
trocar  should  always  give  way  to  a  medium-sized  needle  of  an  exploring- 
syringe  or  aspirator.  The  puncture  is  made  under  strict  aseptic  precautions. 
The  structures  to  be  avoided  are  the  internal  mammary  artery,  the  pleural 
cavity,  and  the  heart.  The  safest  place  for  puncture  is,  in  ordinary  cases, 
the  fifth  left  intercostal  space,  about  half  an  inch  or  an  inch  from  the  margin 
of  the  sternum,  through  which  the  needle  should  be  pushed  in  a  slightly 
upward  and  outward  direction,  so  as  to  avoid  wounding  the  heart.  It  has 
to  travel  1  ^/^  to  2  inches  before  it  enters  the  pericardial  cavity.  If  pus  is 
found  the  case  must  be  treated  by 

Incision  and  Drainage  of  the  Pericardium. — Instead  of  using  a  trocar, 
it  is  much  better  to  make  an  incision  in  the  fifth  intercostal  space,  using 
the  needle  with  which  the  exploratory  puncture  was  made  as  a  guide.  The 
same  precautions  to  prevent  syncope  as  were  recommended  in  the  radical 
operation  for  empyema  should  be  resorted  to  in  these  cases,  and  chloroform 
is  preferable  to  ether  as  an  anaesthetic.  The  intercostal  incision  need  not 
exceed  an  inch  in  length,  and,  as  soon  as  the  pericardium  has  been  opened 
sufficiently  to  allow  the  escape  of  pus,  a  dressing-forceps  may  be  inserted,  and 
the  opening  enlarged  sufficiently  to  enable  the  introduction  of  a  drainage- 
tube  the  size  of  an  ordinary  lead-pencil.  It  has  been  recently  recommended 
that  pericardial  incision  should  be  preceded  by  rib  resection,  and  some  have 
gone  so  far  as  to  propose  a  limited  temporary  resection  of  the  chest-wall  as 
a  preliminary  step  to  incision  and  drainage. 

Irrigation  of  the  pericardial  cavity  is  to  be  avoided  unless  suppuration 
is  complicated  by  putrefaction.  The  drainage-tube  should  not  project  suf- 
ficiently into  the  pericardial  sac  to  come  in  contact  with  the  heart,  and  should 


343  PEINCIPLES    OF    SUKGEEY. 

always  be  of  soft  material,  so  as  not  to  injure  the  heart  should  it  be  too  long. 
The  antiseptic  dressing  can  be  retained  most  effectually  with  several  strips 
of  rubber  adhesive  plaster,  which  should  be  long  enough  to  encircle  the  whole 
chest.  Stoll,  of  Warsaw,  has  reported  a  successful  operation  for  suppurative 
pericarditis.  The  patient  was  an  exhausted  and  emaciated  soldier,  21  years 
of  age.  After  the  sternum  was  trephined  the  pericardium  was  freely  opened 
at  the  level  of  the  second  intercostal  space.  Two  months  after  the  operation 
examination  showed  that  the  pericardial  sac  was  completely  obliterated. 
Gussenbauer,  in  a  patient  15  years  of  age  suffering  from  suppurative  peri- 
carditis after  osteomyelitis,  resected  part  of  the  fifth  rib  near  the  sternum 
before  incising  the  pericardium,  and  the  patient  recovered.  This  modifica- 
tion of  the  ordinary  operation  by  incision  through  the  fifth  intercostal  space 
will  occasionally  present  decided  advantages  in  the  surgical  treatment  of 
pericardial  empyema. 

SUPPUEATIVE    PEEITONITIS. 

A  great  deal  of  confusion  has  recently  arisen  in  the  use  of  the  terms 
septic  and  suppurative  peritonitis.  Etiologically,  they  are  identical;  clin- 
ically, they  differ  in  so  far  that  septic  peritonitis  is  generally  diffuse,  and 
leads  to  a  rapidly  fatal  termination;  while  what  is  known  as  suppurative 
peritonitis  is  more  frequently  circumscribed  and  more  amenable  to  surgical 
treatment.  Both  forms  are  caused  by  infection  with  pus-microbes.  In  the 
septic  variety  death  results  from  intoxication  before  the  pus-microbes  have 
had  time  to  produce  their  specific  pathogenic  effect  on  the  histological  ele- 
ments which  are  destined  to  become  converted  into  pus-corpuscles.  In  sup- 
purative peritonitis  the  pus-microbes  are  either  less  in  number  or  they  meet 
with  conditions  less  favorable  to  the  production  of  a  fatal  amount  of  toxins, 
or,  finally,  the  peritoneum  is  in  a  condition  which  is  unfavorable  to  the  en- 
trance of  pus-microbes  or  their  toxins  into  the  circulation. 

Bacteriological  and  Experimental  Researches. — A  number  of  original 
investigators  have  studied  the  etiology  of  peritonitis  experimentally,  and 
their  work  has  been  of  great  practical  value  in  showing  that  suppurative 
peritonitis  is  not  only  caused  by  the  action  of  pus-microbes,  but  that  it  is 
equally  essential  that  certain  conditions  must  be  present  in  the  peritoneal 
cavity  which  enable  the  pus-microbes  to  produce  their  specific  pathogenic 
effects.  PaAvlowsky  made  ten  series  of  experiments  on  101  animals.  The 
chemical  irritants,  or  cultures,  were  introduced  into  the  peritoneal  cavity 
through  the  cannula  of  a  small  trocar  under  strict  aseptic  precautions,  and 
the  small  wound  was  carefully  sealed  Avith  iodoform  collodion.  The  first 
series  consisted  of  experiments  with  croton-oil  on  3  dogs  and  9  rabbits.  The 
amount  of  croton-oil  injected  in  each  case  varied  from  6  drops  to  ^/lo  drop. 
The  smallest  doses  produced  no  effects.    Large  doses  caused  a  severe,  acute, 


SUPPUEATIVE    PERITONITIS.  •  343 

hsemorrhagic  peritonitis  the  intensity  of  which  was  proportionate  to  the 
quantity  of  the  irritant  injected.  The  peritoneal  exudation,  under  the  micro- 
scope, was  seen  to  contain  red  and  white  blood-corpuscles.  Inoculations  of 
different  nutrient  media  with  the  fluid  yielded  negative  results.  In  the  next 
series  of  experiments  an  aqueous  solution  of  trypsin  and  pancreatin  was  in- 
jected for  the  purpose  of  determining  whether  the  digestive  ferments,  in 
the  event  of  intestinal  perforation,  could  produce  peritonitis.  The  experi- 
ments established  the  fact  that  trypsin  acts  as  a  powerful  irritant  upon  the 
peritoneum.  Injection  of  ^/o  gramme  of  trypsin,  dissolved  in  distilled  water, 
caused  in  rabbits  a  severe  hsemorrhagic  peritonitis,  with  a  copious  exudation, 
and  death  in  from  four  to  four  and  a  half  hours.  In  doses  of  ^/ ^  to  ^/^^ 
gramme  the  same  local  condition  was  produced,  but  death  did  not  occur 
until  twenty  to  twenty-four  hours  after  the  injection.  One-hundredth  (0.01) 
of  a  gramme  produced  no  symptoms.  Nutrient  media  inoculated  with  the 
products  of  inflammation  remained  sterile.  Next,  the  peritoneal  cavity  was 
infected  with  plate-cultures  of  different  microbes  suspended  in  sterilized 
water.  The  first  experiments  were  made  with  non-pathogenic  microbes. 
Four  rabbits  and  one  dog  were  injected  with  large  quantities  of  a  micrococcus 
which  was  obtained  from  a  plate-culture  inoculated  with  pus;  the  micrococ- 
cus was  exactly  similar  to  the  staphylococcus  pyogenes  albus,  for  which  it  was 
first  mistaken.  Later,  it  was  shown  that  it  was  not  a  pus-microbe,  as  it  did 
not  liquefy  gelatin.  All  of  the  animals  recovered.  Two  rabbits  inoculated 
with  an  entire  culture  of  yellow  sarcinse  upon  agar-agar,  mixed  with  ^/^o  drop 
of  croton-oil,  also  recovered.  The  experiments  with  pathogenic  microbes 
always  produced  positive  results.  Three  series,  with  three  separate  microor- 
ganisms, were  made  next.  The  staphylococcus  pyogenes  aureus,  grown  from 
osteomyelitic  pus,  was  first  used.  In  17  out  of  41  experiments  this  microbe 
alone  was  used;  in  11  it  was  mixed  with  croton-oil,  in  6  with  trypsin,  and 
in  7  with  agar-agar.  In  all  cases  where  pure  cultures  were  used  peritonitis 
was  produced,  the  type  varying  according  to  the  number  of  microbes  used. 
The  same  microbes  could  be  cultivated  upon  proper  nutrient  media  from  the 
different  inflammatory  products.  In  hardened  specimens  of  the  inflamed' 
peritoneum,  stained  with  dift'erent  coloring  agents,  the  microorganisms  could 
be  seen  in  the  lymph-spaces.  The  suppurative  type  of  peritonitis  thus  arti- 
ficially produced  became  more  apparent  the  longer  life  was  prolonged.  An 
entire  agar-agar  culture  of  the  bacillus  pyocyaneus  caused  death  from  septic 
peritonitis  in  from  twenty-four  to  forty-eight  hours.  One-fifth  of  this  quan- 
tity proved  harmless.  The  next  series  of  experiments  was  made  to  ascertain 
the  cause  of  peritonitis  after  intestinal  perforation.  The  fresh  intestinal  con- 
tents of  a  healthy  animal,  just  killed,  were  divided  into  three  parts,  one  of 
which  was  at  once  injected  into  several  rabbits,  without  filtration,  in  doses  of 
1  syringeful.    The  second  portion  was  filtered,  and  of  the  filtrate  from  2  to 


344  PEINCIPLES    OF    SURGEEY. 

3  syringefuls  were  injected  into  each  rabbit.  The  third  portion  was  ster- 
ilized, according  to  Tyndall's  direction,  for  eight  days,  and  then  1  syringef ul 
was  injected  into  the  abdominal  cavity  of  each  animal.  The  results  were  as 
follow:  Four  rabbits  died  of  fibrinous,  suppurative  peritonitis  from  the  in- 
jections with  the  first  portion.  Four  rabbits  injected  with  the  filtered  fgeces 
recovered,  as  did  one  animal  inoculated  with  the  sterilized  portion.  This 
author  maintains  that  the  fibrinous  form  of  peritonitis  is  the  least  dangerous, 
as  the  layers  of  fibrin  tend  to  limit  the  entrance  of  microbes  into  the  circula- 
tion, while  they  also  retard  the  local  diffusion  of  the  injection.  The  fibrino- 
suppurative  variety  is  the  next  least  dangerous  form,  while  in  the  most  rap- 
idly fatal  cases  of  septic  peritonitis  the  local  lesion  is  not  characterized  by 
any  macroscopical  tissue-changes.  Putrescible  substances,  when  injected 
in  small  quantities,  were  rapidly  absorbed  without  producing  peritoni- 
tis; but  when  the  quantity  injected  was  large,  and  insufflation  of  unfil- 
tered  air  was  practiced  at  the  same  time,  peritonitis,  with  putrefaction  and 
death  from  septic  intoxication,  occurred. .  Grawitz  proved  that  saprophytic 
bacteria,  when  injected  into  a  normal  peritoneal  cavity,  were  promptly  de- 
stroyed and  absorbed.  In  cases  in  which  the  injection  was  made  into  a  peri- 
toneal cavity  which  had  previously  undergone  alterations  by  injury  or  dis- 
ease, or  in  which  the  quantity  of  fluid  was  too  great  for  speedy  absorption, 
symptoms  of  intoxication,  as  described  by  Weber,  resulted;  but  these  symp- 
toms were  unaccompanied  by  suppurative  peritonitis.  A  healthy  peritoneal 
cavity  has  also  been  found  capable  of  disposing  of  a  limited  quantity  of  pure 
cultivations  of  pus-microbes,  the  microbes  being  removed  by  absorption  and 
destroyed  in  the  circulation  or  eliminated  through  the  excretory  organs.  But 
when  pyogenic  organisms  are  introduced  into  an  abdominal  cavity,  in  which 
the  absorptive  capacity  of  the  peritoneum  has  been  diminished  or  suspended 
by  antecedent  pathological  conditions,  suppurative  peritonitis  is  the  usual 
result.  When  pus-microbes  are  introduced  in  large  quantities,  even  into  a 
healthy  peritoneal  cavit}^,  the  preformed  toxins,  by  their  chemical  action,  so 
alter  the  tissues  that  the  process  of  absorption  is  impaired,  and  suppurative 
peritonitis  again  results  in  consequence  of  the  retention  of  pus-microbes  in 
tissues  prepared  for  their  pathogenic  action. 

Einne  is  of  the  opinion  that,  on  account  of  the  rapidity  with  which  ab- 
sorption takes  place  in  the  peritoneal  cavity,  the  peritoneum,  when  in  a  nor- 
mal condition,  is  almost  immune  to  infection  with  pus-microbes.  He  in- 
jected from  30  to  35  cubic  centimetres  of  a  pure  culture  of  pus-microbes, 
suspended  in  sterilized  water,  into  the  peritoneal  cavity  of  healthy  animals, 
and  never  succeeded,  in  this  manner,  in  producing  peritonitis.  He  had  no 
better  success  with  injections  of  a  mixture  of  a  gelatin  culture  of  staphylo- 
coccus pyogenes  aureus  and  a  turbid  bouillon  culture  of  the  same  coccus. 
He  also  made  daily  injections  with  a  putrid  fluid,  to  which  was  added  a  cult- 


SUPPURATIVE    PERITONITIS.  345 

ure  of  the  staphylococcus  pyogenes  aureus,  without  producing  peritonitis. 
The  experiments,  as  a  rule,  were  made  on  dogs,  although,  in  several  instances, 
rabbits,  guinea-pigs,  and  white  rats  were  used.  He  believes  that  the  differ- 
ence in  the  results  obtained  by  him  and  Grawitz,  as  compared  with  Pawlow- 
sky,  consists  in  the  nature  of  the  abdominal  wound.  Pawlowsky  made  an 
incision  down  to  the  muscles  and  then  perforated  the  abdominal  wall  with  a 
blunt  trocar;  Avhile  he  and  Grawitz  used  a  sharp,  hollow  needle  for  making 
the  intraperitoneal  injection.  To  prove  that  his  injections  reached  the  peri- 
toneal cavity,  he  added  coal-dust  to  the  fluid,  which  he  found  at  the  post- 
mortems as  fine  particles  clinging  to  the  peritoneal  surface. 

Clinical  and  Bacteriological  Studies. — Peritonitis  caused  by  infection 
from  without  through  a  penetrating  wound  or  after  abdominal  operations  is 
generally  due  to  the  presence  of  the  ordinary  pus-microbes.  Peritonitis  re- 
sulting from  intraabdominal  infection,  intestinal  perforation,  or  rupture  of 
an  intraabdominal  abscess,  on  the  other  hand,  is  most  frequently  caused  by 
infection  with  the  colon  bacillus  with  or  without  mixed  infection  with  pus- 
microbes.  Frankel  found  the  streptococcus  pyogenes  in  a  great  variety  of 
puerperal  diseases,  especially  in  cases  in  which  the  local  affection  implicated 
the  lymphatic  vessels.  In  such  cases  the  microbes  found  entrance  into  the 
pelvic  tissues  from  abrasions  or  ulcers  in  the  vagina,  and  by  extension  of  the 
inflammatory  process  the  broad  ligaments  and  the  peritoneum  are  success- 
ively involved;  after  the  peritoneum  has  once  been  reached  rapid  diffusion 
takes  place,  and,  finally,  the  diaphragm  and  pleura  are  implicated  in  the  same 
process,  and  the  microbes  reach  the  blood  and  cause  sepsis  and  pysemia. 

In  suppurative  peritonitis  without  the  existence  of  a  direct  communica- 
tion with  the  external  surface  or  the  intestinal  canal,  we  must  take  it  for 
granted  that  pus-microbes  may  have  entered  the  peritoneal  cavity  through 
the  Fallopian  tubes,  through  slight  defects  of  the  intestinal  mucous  mem- 
brane, and  from  here  through  the  lymphatic  channels  into  the  peritoneal 
cavity,  or  through  a  minute  perforation  the  existence  of  which  cannot  be 
demonstrated  during  life  and  often  not  at  the  post-mortem  examination,  or, 
finally,  localization  of  pus-microbes  from  the  blood  in  the  capillaries  of  the 
peritoneum.  Weichselbaum  has  shown  that  peritonitis  is  not  always  caused 
by  pus-microbes,  as  has  been  heretofore  believed,  as  he  found  the  diplococcus 
of  pneumonia  unaccompanied  by  any  other  microorganisms  in  3  cases  of  peri- 
tonitis. In  1  case  peritonitis  and  pneumonia  existed  at  the  same  time;  in 
the  other  double  pleuritis  followed  the  peritonitis;  but  in  the  last  case  peri- 
tonitis was  undoubtedly  primary,  and,  in  the  absence  of  any  other  microbes 
in  the  products  of  the  inflammation,  must  have  been  caused  by  the  diplo- 
coccus of  Friedlander.  In  another  case  following  rupture  of  the  spleen  in 
the  course  of  typhoid  fever  he  obtained  from  the  exudate  a  pure  culture  of 
the  typhoid  bacillus.     Frankel  made  a  bacteriological  study  of  31  cases  of 


346  PRINCIPLES    OF    SURGERY. 

peritonitis,  with  the  following  result:  Bacillus  coli  communis,  nine  times; 
streptococci,  seven  times;  bacillus  lactis  aerogenes,  twice;  micrococcus  pneu- 
monia crouposge,  once;  staphylococcus  pyogenes  aureus,  once.  In  3  cases 
the  bacillus  coli  communis  was  present  in  association  with  other  bacilli,  and 
in  4  cases  the  bacteriological  examination  yielded  a  negative  result.  There 
can  be  no  doubt  that  septic  peritonitis  may  be  caused  by  pathogenic  microbes 
which — at  present  at  least — are  not  classified  with  the  pus-microbes;  but  sup- 
purative peritonitis  can  have  no  other  bacteriological  cause,  and  in  most  cases 
of  septic  peritonitis  infection  with  pus-microbes  can  be  demonstrated  by 
clinical  evidences  as  well  as  bacteriological  and  experimental  demonstration. 

Difference  between  Plastic  and  Suppurative  Peritonitis. — ^The  greatest 
clinical  difference  between  simple  or  plastic  peritonitis  produced  by  trauma 
or  chemical  irritants  and  septic  or  suppurative  peritonitis  consists  in  the  cause 
and  extent  of  the  inflammation.  Plastic  inflammation  produced  by  aseptic 
causes  remains  limited  to  the  seat  of  trauma  or  chemical  irritation,  and  does 
not  extend  much  beyond  the  surface-area  to  Avhich  the  stimulus  is  applied; 
while  septic  peritonitis  is  always  characterized  by  its  progressive  character, 
as  the  cause  upon  which  it  depends  is  reproduced  within  the  peritoneal  cav- 
ity. A  plastic  peritonitis  is  attended  b}^  febrile  disturbances,  caused  by  the 
introduction  into  the  circulation  of  the  products  of  coagulation-necrosis  or 
metabolic  tissue-changes;  in  septic  peritonitis  the  general  symptoms  are 
produced  by  the  entrance  of  pus-microbes  into  the  general  circulation  and 
their  toxins,  both  of  which  are  also  reproduced  in  the  blood  and  other  organs 
of  the  body  in  which  secondary  localization  may  take  place. 

The  Cause  of  Suppurative  Peritonitis. — Experimental  research  has  dem- 
onstrated that  in  the  causation  of  suppurative  peritonitis  two  conditions 
must  be  preseiit  at  the  same  time:  1.  Pyogenic  bacteria.  2.  A  wound  of  the 
peritoneal  surface,  or  antecedent  pathological  conditions  which  diminish  the 
absorptive  capacity  of  the  peritoneum.  The  microbic  cause  is  the  essential 
etiological  factor,  as  without  it  the  other  conditions  would  not  result  in  this 
form  of  peritonitis.  If  pus-microbes  are  introduced  into  the  peritoneal 
cavity  in  sufficient  quantity  suppurative  peritonitis  is  produced,  as  the  pre- 
formed toxins  create  the  indirect  etiological  conditions.  A  number  of  bac- 
teria which  at  present  are  not  classified  with  the  pus-microbes  may,  under 
certain  favorable  conditions,  manifest  pyogenic  properties;  and  thus,  when 
introduced  into  a  peritoneal  cavity  predisposed  to  suppuration,  cause  an  at- 
tack of  suppurative  peritonitis.  Thus  we  have  seen  that  Weichselbaum  has 
found  the  diplococcus  of  pneumonia  in  the  inflammatory  product  of  three 
cases  of  peritonitis,  and  as  no  other  microbes  were  present  it  is  reasonable  to 
assume  that  suppuration  was  caused  by  this  microbe.  In  serous  cavities  gon- 
orrhoeal  pus  produces,  as  a  rule,  a  circumscribed  abscess.  Sinclair,  in  his  ex- 
cellent monograph  on  "Gonorrhoeal  Infection  in  Women,"  after  describing 


SUPPUEATIVE    PEEITONITIS.  347 

the  gonorrhoeal  infection  from  the  vagina,  says:  "The  proper  character  and 
the  result  of  the  pathogenous  activity  of  the  gonorrhoeic  microbes  are  there- 
fore seen,  pure  and  unadulterated,  in  the  tube.  They  cause  purulent  inflam- 
mation of  the  mucous  membrane,  but  the  surrounding  connective  tissue  re- 
mains free  from  them.  The  gonorrhoeic  tubal  pus  is  evacuated  into  the  peri- 
toneum, and,  whereas  in  other  conditions  the  bursting  of  an  abscess  into  the 
abdominal  cavity  is  followed  by  the  gravest  consequences,  in  this  case  the 
whole  process  terminates  with  a  circumscribed  inflammation,  encapsuling  the 
exuded  pus.  The  cause  of  this  diflerence  is  the  varying  pathogenic  value  of 
the  organisms  which  are  contained  in  the  pus.  A  puerperal  pelvic  cellulitic 
abscess,  bursting  into  the  peritoneum,  causes  general  peritonitis,  because  it 
contains  pyogenous  streptococci,  which  rapidly  multiply  in  serous  cavities 
and  are  capable  of  exerting  the  most  deleterious  effects.  Gonorrhoeal  tubal 
pus  cannot  do  this;  its  microbes  do  not  find  in  the  peritoneum  conditions 
for  their  increase  to  the  same  extent;  the  pus,  therefore,  acts  as  an  aseptic 
foreign  body,  becomes  encapsulated,  and  is  finally  absorbed.  Practically,  it 
is  well  known  that  when  gonorrhoeal  infection  extends  from  the  Fallopian 
tubes  to  the  peritoneum  by  leakage  of  pus  into  the  peritoneal  cavity  from 
the  peritoneal  extremity  of  the  tube,  or  rupture  of  a  pus-tube,  the  result  is 
a  circumscribed  suppurative  peritonitis,  with  the  formation  of  a  circum- 
scribed abscess." 

Wertheim's  investigations  have  shown  that  the  gonococcus  can  set  u]3  a 
peritonitis  in  animals  whose  mucous  membranes  are  refractory  to  the  action 
of  this  microbe.  From  this  it  follows  that  the  gonococcus  will  produce  peri- 
tonitis in  man,  whose  mucous  membranes  are  very  susceptible  to  gonorrhoeal 
inflammation.  He  has  also  demonstrated  that  the  gonococcus  can  penetrate 
pavement  as  well  as  cylindrical  epithelium.  Under  certain  favorable  circum- 
stances it  also  gains  entrance  into  the  lymphatics. 

That  encapsulation  of  gonorrhoeal  pus  does  not  invariably  follow  gonor- 
rhoeal infection  of  the  peritoneal  cavity  is  well  shown  by  a  case  reported  by 
Loven,  which  is  by  no  means  an  isolated  one.  The  source  of  infection  could 
not  be  learned  in  this  case,  but  the  diagnosis  of  gonorrhoeic  ascending  in- 
fection Avas  positive.  The  disease  commenced  as  an  ordinary  vulvo-vaginal 
blennorrhoea,  which  consecutively  extended  to  the  uterus,  Fallopian  tubes, 
and  terminated  in  pelvic  and  diffuse  peritonitis.  It  is  possible  that  in  this 
particular  case  a  secondary  infection  with  pus-microbes  had  taken  place,  as, 
at  the  necrops}^,  chain  cocci  were  found  in  the  peritoneal  cavity.  The  rela- 
tion of  the  streptococcus  of  erysipelas  to  peritonitis  will  be  considered  in  the 
chapter  on  "Erysipelas."  Abdominal  surgeons  are  very  well  aware  of  the 
clinical  fact  that  septic  or  suppurative  peritonitis,  after  laparotomy,  is  more 
prone  to  develop  if  fluids,  and  especially  blood,  are  allowed  to  remain  in  the 
abdominal  cavity;   and  consequently  resort  to  a  careful  toilet  of  the  cavity, 


348  PEINCIPLES    OF    SUEGERY. 

and,  if  there  is  any  reason  to  expect  a  reaccumnlation,  to  drainage.  Fluid  in 
the  peritoneal  cavity  except  saline  solution  prevents  the  removal  of  the 
pus-microbes  by  absorption,  and  if  they  remain  they  multiply  and  cause 
peritonitis.  For  years  it  has  been  customary  to  resort  to  the  use  of  opium 
in  the  prevention  and  treatment  of  peritonitis,  until  Tait  showed  the  fallacy 
of  such  treatment  and  recommended  cathartics.  The  treatment  of  incipient 
peritonitis  by  a  brisk  saline  cathartic  is  now  generally  practiced,  and  the  re- 
sults have  been  exceedingly  satisfactory.  What  is  the  modus  operandi  of 
saline  cathartics  in  the  prevention  of  diffuse  septic  peritonitis?  The  most 
rational  answer  to  this  question  is  that  a  brisk  saline  cathartic  promotes  ab- 
sorption of  fluids  from  the  peritoneal  cavity,  and  by  so  doing  removes  the 
indirect  causes  of  peritonitis,  and,  at  the  same  time,  favors  the  elimination 
of  pyogenic  microbes.  Intraabdominal  wounds  not  covered  with  peritoneum 
are  potent  factors  in  the  development  of  peritonitis  in  an  abdominal  cavity 
which  is  not  absolutely  aseptic,  as  the  raw  surfaces  furnish  a  considerable 
quantity  of  wound-secretion,  on  the  one  hand,  and,  on  the  other,  diminish 
the  absorptive  capacity  of  the  peritoneum.  This  cause  of  peritonitis  should 
be  eliminated,  as  far  as  possible,  in  all  intraabdominal  operations,  by  avoid- 
ing unnecessary  injury  to  the  peritoneum,  and  by  covering  denuded  surfaces 
with  this  membrane  wherever  it  can  be  done.  Another  indirect  cause  of  peri- 
tonitis is  intestinal  obstruction.  The  intestine  above  the  seat  of  obstruction 
becomes  dilated,  congested,  softened,  and,  in  consequence  of  these  changes, 
permeable  to  pathogenic  microbes,  which  are  always  present  in  the  intestinal 
canal  under  these  circumstances. 

Alapy  has  made  a  series  of  experiments  in  Weichselbaum's  laboratory 
to  ascertain  if  pathogenic  microbes  could  pass  through  the  healthy  stomach 
into  the  intestines.  He  experimented  with  pus-microbes  and  the  streptococ- 
cus of  erysipelas.  From  these  experiments  he  came  to  the  conclusion  that 
the  virulence  of  these  microbes  is  destroyed  in  a  healthy  stomach,  but  when 
the  gastric  secretion  has  suffered  diminution  of  acidity,  or  has  become  alka- 
line, the  microbes  do  not  lose  their  pathogenic  properties,  and  pass  into  the 
intestines  in  an  active  condition.  In  cases  of  intestinal  obstruction  the  phys- 
iological functions  of  the  stomach  are  disturbed,  and  conditions  are  created 
which  preserve  the  virulence  of  pathogenic  microorganisms  on  their  Avay 
into  the  intestinal  canal.  The  immediate  cause  of  death  in  many  cases  of 
intestinal  obstruction  is  diffuse  septic  peritonitis.  In  the  different  forms  of 
perforative  peritonitis  the  disease  is  caused  by  the  escape  of  fluids  containing 
pyogenic  bacteria,  and  the  type  and  gravity  of  the  disease  are  greatly  modified 
by  the  amount  of  fluid  which  enters  the  peritoneal  cavity  and  the  number  of 
microbes  which  it  contains.  Perforation  of  a  typhoid  or  tubercular  ulcer  is 
always  a  grave  occurrence,  as  the  fluid  which  escapes  is  usually  considerable 
in  quantity  and  contains  numerous  pathogenic  microbes.    Perforating  ulcer 


SUPPUEATIVE    PERITONITIS.  349 

of  the  stomach  is  more  frequently  followed  by  circumscribed  plastic  peri- 
tonitis, which  shuts  out  the  general  peritoneal  cavity.  Perforation  of  the 
appendix  vermiformis  is  followed  as  often  by  circumscribed  suppurative  peri- 
tonitis as  by  diffuse  septic  peritonitis.  The  same  can  be  said  of  perforation 
of  the  gall-bladder. 

Symptoms  and  Diagnosis.  —  Diffuse  septic  peritonitis  spreads  over  the 
entire  peritoneal  cavity  almost  with  lightning  speed.  The  first  symptoms 
are  those  of  shock.  If  the  disease  follow  an  abdominal  section,  it  is  often 
difficult  to  determine  whether  the  conditions  presented  are  due  to  shock  or 
diffuse  peritonitis,  as  the  latter  may  set  in  in  a  few  hours  after  the  operation 
and  prove  fatal  within  twenty-four  hours.  The  temperature  is  variable.  It 
may  remain  normal  or  become  even  subnormal,  or  it  may  at  first  be  only 
slightly  increased  and  gradually  reach  103°  to  104°  F.  Vomiting  and  diar- 
rhoea are  frequently  conspicuous  symptoms.  In  other  cases  the  symptoms 
point  to  intestinal  obstruction.  In  extensive  plastic  peritonitis  the  immob- 
ilization of  a  considerable  portion  of  the  small  intestine  may  give  rise  to 
persistent  vomiting  and  absolute  constipation.  Again,  arrest  of  the  faecal 
circulation  may  be  caused  by  the  tympanites  alone,  while  perforative  peri- 
tonitis is  attended  by  a  local  and  general  shock,  which  causes  intestinal 
paresis  through  the  inhibitory  action  of  the  sympathetic  nerves.  ITeusner 
has  observed  that  perforative  peritonitis  gives  rise  to  disturbances  simulating 
intestinal  obstruction  by  arresting  intestinal  movements.  He  narrates  the 
histories  of  2  cases  of  this  kind  in  which  the  symptoms  of  intestinal  obstruc- 
tion were  so  prominent  that  laparotomy  was  performed.  In  both  cases  per- 
forative peritonitis,  but  not  occlusion,  was  found.  Henrot,  in  his  classical 
monograph  on  "Pseudostrangulation,"  describes  a  number  of  cases  of  per- 
foration of  the  gall-bladder  and  the  processus  vermiformis,  where  the  symp- 
toms during  life  had  pointed  so  strongly  to  the  existence  of  intestinal  ob- 
struction that  a  wrong  diagnosis  was  made  by  able  clinicians.  He  also  calls 
attention  to  those  cases  of  paralytic  obstruction  which  are  often  observed- 
after  herniotomy,  and  in  cases  of  strangulation  of  the  appendix  vermiformis 
and  testicle.  The  intestinal  paresis,  where  it  is  not  the  result  of  inflamma- 
tion, must  be  looked  upon  as  a  reflex  symptom. 

Physical  signs  and  symptoms  are  sometimes  utterly  inadequate  to  dis- 
tinguish between  acute  intestinal  obstruction  and  diffuse  peritonitis.  In 
differentiating  between  these  two  conditions  it  must  be  remembered  that,  in 
the  absence  of  a  swelling,  absolute  constipation  and  fgecal  vomiting  are  the 
most  characteristic  symptoms  of  obstruction,  and  that  in  peritonitis  the  pain 
is  severe  and  continuous,  with  diffuse  tenderness,  tympanites,  and  absence  of 
visible  intestinal  coils.  In  mechanical  obstruction  of  the  bowels  the  tem- 
perature is,  as  a  rule,  not  above  normal  unless  complications  have  set  in; 
while  in  peritonitis  a  rise  in  temperature  is  the  rule,  although  in  some  of  the 


350  PRINCIPLES    OF    SUEGEEY. 

gravest  cases  it  is  subnormal.  Many  cases  of  alleged  recovery  from  intestinal 
obstruction  without  operation  undoubtedly  were  cases  of  a  dynamic  obstruc- 
tion, and  the  recovery  was  either  entirely  spontaneous  or  facilitated  by  means 
which  assisted  in  the  restoration  of  peristaltic  action.  In  1851  a  patient  was 
admitted  into  Dupuytren^s  ward  with  well-marked  symptoms  of  acute  intes- 
tinal obstruction.  This  eminent  surgeon  gave  it  as  his  opinion  that  without 
an  operation  a  fatal  termination  was  inevitable,  but  the  patient  objected  to 
the  operation  and  was  transferred  to  another  ward,  where  he  recovered  in 
three  days  under  the  use  of  simple  cathartics. 

Numerous  similar  cases  could  be  cited  in  illustration  of  the  difficulty 
of  differentiating  in  all  eases  between  mechanical  occlusion  and  a  dynamic 
obstruction.  In  cases  of  perforative  peritonitis  and  peritonitis  with  putre- 
faction the  presence  of  gas  in  the  free  peritoneal  cavity  gives  rise  to  an  im- 
portant physical  sign.  In  tympanites  from  peritonitis  without  perforation 
and  intestinal  obstruction,  the  distended  intestines  push  the  liver  in  an  up- 
ward direction;  hence,  on  percussion,  the  liver-dullness  is  transferred  higher 
up.  But,  under  the  circumstances  mentioned  above,  the  gas  in  the  free 
abdominal  cavity  occupies  the  space  between  the  liver  and  the  chest-wall; 
consequently  the  liver-dullness  has  disappeared  and  the  space  over  the  organ 
is  tympanitic  on  percussion.  One  of  the  most  constant  signs  in  peritonitis 
is  the  small,  rapid,  compressible  pulse.  In  diffuse  peritonitis  it  usually  ranges 
between  120  and  140.  In  rapidly-fatal  diffuse  septic  peritonitis  pain  is  often 
wanting.  In  circumscribed  peritonitis  pain  and  tenderness  are  limited  to  the 
affected  region.  Tympanites  is  often  a  most  distressing  symptom  in  circum- 
scribed peritonitis,  and  may  be  entirely  absent  in  the  most  fatal  form  of 
septic  peritonitis.  Eigidity  of  the  abdominal  muscles  is  an  indication  of 
peritonitis,  while  it  is  absent  in  uncomplicated  intestinal  obstruction.  In 
suppurative  peritonitis  the  presence  of  pus  in  considerable  quantity  is  indi- 
cated by  the  physical  signs  arising  from  the  accumulation  of  fluid,  either  in 
the  free  peritoneal  cavity  or  in  a  circumscribed  space  of  it.  If  the  pus  is  not 
confined  by  adherent  intestines  and  plastic  exudation,  it  will  gravitate  toward 
the  most  dependent  portion  of  the  peritoneal  cavity,  and,  on  this  account,  the 
area  of  dullness  will  vary  according  to  the  position  of  the  patient.  In  cir- 
cumscribed suppurative  peritonitis  the  pus  is  confined  in  a  limited  space  by 
adherent  abdominal  organs  and  fibrinous  exudation,  and  will  then  present 
all  the  signs  and  symptoms  of  a  deep-seated  abscess.  To  determine  the  char- 
acter of  peritoneal  effusion,  or  of  the  contents  of  a  circumscribed  intraperi- 
toneal inflammatory  swelling,  it  is  necessary  to  resort  to  an  exploratory 
puncture.  The  needle  is  inserted  at  a  point  where  the  fluid  is  in  contact  with 
the  abdominal  wall,  and,  in  the  circumscribed  form  of  peritonitis,  in  a  place 
where  the  puncture  can  be  made  without  traversing  the  free  peritoneal  cavity. 

Treatment.  —  In  perforative  peritonitis  cathartics  are  absolutely  con- 


SUPPUEATIVE    PEKITONITIS.  351 

traindicated^  as  increased  peristalsis  would  aggravate  the  existing  conditions 
by  increasing  the  extravasation  and  by  preventing  limitation  of  the  infection. 
In  such  cases  opium  should  be  administered  to  diminish  the  peristalsis^  to 
relieve  pain^  and  to  diminish  shock.  The  subsequent  safety  of  the  patient 
will  rest  on  an  early  radical  treatment  by  laparotomy.  Unless  the  location 
of  the  perforation  can  be  ascertained  beforehand,  the  incision  should  be  made 
in  the  median  line.  In  cases  of  perforation  of  the  appendix  vermiformis  an 
incision  extending  from  the  middle  of  Poupart^s  ligament  to  a  point  half- 
way between  the  anterior-superior  spinous  process  of  the  ilium  and  umbilicus 
will  secure  most  direct  access  to  the  seat  of  perforation.  Perforating  tuber- 
cular and  typhoid  ulcers  are  found  most  frequently  in  the  ileo-csecal  region. 
If,  on  opening  the  abdominal  cavity,  the  perforation  cannot  be  readily  found, 
it  is  better  to  resort  to  rectal  insufflation  of  hydrogen-gas  at  once,  which  will 
show  with  unfailing  certainty  not  only  that  a  perforation  exists,  but  also  its 
exact  location.  In  multiple  perforations  the  same  diagnostic  test  is  almost 
indispensable,  as  it  will  avoid  the  great  mistake  of  leaving  a  perforation  un- 
sutured.  The  perforations  are  treated  in  the  same  manner  as  an  incised 
wound.  Care  must  be  taken  to  suture  the  opening  in  a  direction  that  will 
interfere  the  least  with  the  lumen  of  the  intestine.  Fine  aseptic  silk  should 
always  be  used  in  preference  to  catgut;  at  least  two  rows  of  sutures  must  be 
applied. 

After  suturing  the  perforation  the  abdominal  cavity  is  washed  out  freely 
with  warm  saline  solution.  Drainage  in  these  cases  must  never  be  omitted, 
as  the  operator  has  no  assurance  that  the  peritoneal  cavity  has  been  rendered 
perfectly  aseptic.  Laplace  has  recently  recommended  continuous  irrigation 
with  saline  solution  in  the  treatment  of  diffuse  septic  peritonitis,  and  this 
suggestion  has  much  to  recommend  it  to  an  extensive  trial.  If  the  intestines 
are  much  distended  and  paretic,  evacuation  through  one  or  more  incisions 
and  injection  into  the  bowel  of  a  saturated  solution  of  sulphate  of  magnesia, 
as  suggested  by  McCosh,  should  be  practiced.  A  threatened  septic  peritoni- 
tis after  laparotomy  can  often  be  aborted  by  giving  half  an  ounce  of  sulphate 
of  magnesia,  dissolved  in  a  glassful  of  water,  upon  the  appearance  of  the  first 
symptoms.  The  administration  of  the  same  drug  in  half-drachm  or  drachm 
doses  every  half-hour  as  recommended  by  Byford  is  preferable  to  a  single 
large  dose.  The  action  of  the  saline  cathartic  can  be  hastened  and  its  bene- 
ficial effects  increased  by  the  administration  of  a  turpentine  enema.  After 
the  bowels  have  been  moved  thoroughly  opium  can  be  given  in  sufficient 
doses  to  relieve  pain.  If  the  symptoms  do  not  subside  under  this  treatment, 
the  abdominal  wound  is  opened  sufficiently  to  permit  free  irrigation  with 
salicylated  water,  and  a  Keith  drain  is  inserted,  loosely  packed  with  iodoform 
gauze,  and  a  copious  hygroscopic  sterile  dressing  applied.  Many  surgeons 
of  the  present  time  doubt  the  occurrence  of  peritonitis  without  a  local  source 


352  PEINCIPLES    OF    SUEGERY. 

of  infection,  and  there  can  be  no  donbt  that  so-called  spontaneous  peritonitis 
without  such  a  local  focus  is  exceedingly  rare,  hut  its  existence  cannot  be 
denied.  If  suppuration  in  a  joint,  in  the  pleural  cavity,  or  in  the  pericar- 
dium can  occur  without  such  a  direct  local  cause,  there  is  no  reason  why 
suppurative  peritonitis  should  not,  at  least  in  exceptional  cases,  have  a  similar 
origin.  A  locus  minoris  resisteniice  of  a  non-suppurative  type  in  any  part 
of  the  peritoneal  cavity  can  determine  localization  of  pus-microbes  here  as 
well  as  in  any  other  part  of  the  body.  In  opening  the  abdomen  for  the 
evacuation  of  pus  the  surgeon  must  look  for  a  primary  lesion;  but  he  will 
not  always  find  it,  as  it  is  not  invariably  present.  Diffuse  septic  and  suppura- 
tive peritonites  are  seldom,  if  ever,  cured  by  laparotomy.  Localized  suppura- 
tive peritonitis  brought  about  by  curable  causes  is  amenable  to  successful  sur- 
gical treatment.  An  operation  is  always  indicated  as  soon  as  the  presence  of 
pus  is  ascertained.  Delay  is  dangerous  in  these  cases,  as  the  delicate  walls, 
composed  of  plastic  exudation,  may  yield  to  the  pressure,  and  the  extravasa- 
tion of  pus  infects  a  new  portion  of  the  peritoneal  cavity,  or  perhaps  its 
entire  extent.  In  circumscribed  suppurative  peritonitis  the  incision  is  to  be 
made  at  a  point  where  the  pus  is  in  contact  with  the  abdominal  wall.  The 
abdomen  is  to  be  opened  by  a  careful  dissection,  and  if  the  incision  lead 
directly  into  the  pus-cavity  this  is  drained  and  washed  out  with  saline  solu- 
tion or  a  weak  antiseptic  solution.  If,  on  cutting  through  the  peritoneum, 
no  pus  is  found,  and  the  peritoneal  cavity  has  been  opened,  it  is  not  safe  to 
evacuate  the  pus  until  the  cavity  has  been  shut  out  by  suturing  the 
abscess-wall  to  the  parietal  peritoneum,  or  packing  the  wound  for  a  few 
days  with  iodoform  gauze,  and  postponing  the  opening  of  the  abscess  until 
firm  adhesions  have  formed  between  the  margins  of  the  wound  and  the  sur- 
face of  the  abscess-wall.  This  method  of  operating  in  two  stages  must  be 
frequently  resorted  to  in  the  treatment  of  pelvic  abscess,  abscess  of  the  liver, 
and  empyema  of  the  gall-bladder.  If  the  primary  disease  which  has  caused 
the  intraperitoneal  suppuration  can  be  discovered,  this  must  receive  special 
attention.  In  circumscribed  suppurative  peritonitis  in  the  right  iliac  region 
caused  by  perforation  of  the  appendix  vermiformis  the  appendix  must  be 
looked  for,  and  when  found  perforated  it  is  excised  near  its  attachment  to 
the  cgeeum,  after  tying  its  base  with  a  fine-silk  ligature,  if  this  can  be  done 
without  risk  of  exposing  the  free  peritoneal  cavity  to  infection,  otherwise  the 
abscess  is  simply  drained.  All  operations  for  suppurative  peritonitis  are  to 
be  conducted  upon  rigid  aseptic  principles,  and  aseptic  measures  are  to  be 
followed  without  relaxation  during  the  entire  after-treatment.  As  patients 
suffering  from  peritonitis  are  always  greatly  debilitated  from  the  effects  of 
the  disease  as  well  as  from  lack  of  solid  food,  which,  for  well-founded  reasons, 
must  be  withheld,  every  effort  should  be  made  to  sustain  strength  by  the 
systematic  administration  of  liquid  nourishment  and  alcoholic  stimulants. 


SUPPUEATIYE    PEEITONITIS.  353 

Absolute  rest  must  be  enforced  for  the  purpose  of  limiting  the  extension  of 
the  disease  and  with  a  view  of  aiding  the  process  of  repair.  Suspension 
of  stomach-feeding  is  one  of  the  most  important  things  in  securing  intestinal 
rest. 


CHAPTEE  XIV. 


Septicemia. 


Septicemia,  septgemia,  sepsis,  are  synonymous  terms  used  to  designate 
a  general  febrile  affection  caused  by  the  introduction  into  the  circulation  of 
the  products  of  fermentation  or  putrefaction,  and  which  is  characterized  by 
definite  blood-changes,  a  typical  series  of  inflammatory  processes,  a  peculiar 
group  of  nervous  symptoms  and  critical  discharges.  Clinically,  and  prob- 
ably etiologically,  it  is  closely  related  to  pysemia.  The  older  pathologists  en- 
tertained the  belief  that  in  cases  of  septicaemia  the  blood  itself  was  the  seat 
of  putrefactive  changes.  At  present  it  is  generally  conceded  that  it  results 
from  the  introduction  into  the  circulation  of  septic  microorganisms  or  their 
toxins.  The  symptoms  do  not  suffice  for  a  full  characterization  of  the  dis- 
ease, but  the  specific  infection  is  the  integral  and  essential  factor. 

BACTEKIOLOGICAL    EESEARCHES. 

Septic  processes  were  among  the  first  to  excite  interest  in  the  part  played 
by  microorganisms  in  disease.  Although  some  of  the  best  pathologists  have 
been  diligently  investigating  this  subject  for  years,  we  still  remain  in  the 
dark  concerning  its  true  etiology  and  its  relation  to  other  infective  processes. 
True  sepsis  is  now  regarded  as  a  general  infection  from  some  local  source,  un- 
attended by  any  gross  pathological  changes.  Some  writers  have  claimed  the 
etiological  difference  between  septicemia  and  pysemia  to  be  a  quantitative  and 
not  a  qualitative  one,  while  others  maintain  that  pysemia  is  a  specific  disease 
sui  generis,  and  that  it  is  in  nowise  related  to  sepsis.  There  can  be  no  doubt 
that  true  progressive  sepsis,  if  not  invariably,  is,  at  least  frequently,  caused  by 
the  same  microbes  which  produce  pysemia.  As  we  have  seen  in  the  foregoing 
chapter,  the  same  microbes,  when  introduced  into  the  peritoneal  cavity,  may 
either  cause  a  circumscribed  suppurative  peritonitis  or  a  diffuse  septic  peri- 
tonitis, with  all  the  clinical  features  of  progressive  intoxication.  The  first 
reliable  investigations  into  the  microbic  origin  of  sepsis  were  made  by  Eind- 
fieisch  in  1866,  and,  somewhat  later,  by  Klebs,  Eecldinghausen,  Waldeyer, 
and  Hueter.  Eindfleisch  found  bacteria  in  abscesses,  while  the  researches  of 
Klebs  initiated  a  new  era  in  the  etiology  of  septic  diseases.  Klebs  differen- 
tiated between  septicasmia  and  pysemia,  although  he  claimed  that  putrid  in- 
toxication and  septic  infection  were  the  same.  In  the  tissues  altered  by  septic 
processes,  and  in  the  lymph-spaces  and  in  the  blood,  he  found  a  microbe,  a 
round  coccus,  isolated  and  in  groups,  which  he  termed  microsporon  septicum. 

Septicaemia  in  Mice. — One  of  the  best  descriptions  of  true  progressive 

(354) 


BACTEKIOLOGICAL  EESEARCHES.  355 

septiea?inia  that  lias  ever  iDeen  given  is  by  Koch  on  septicemia  in  mice.  He 
used  the  same  metliod  which  was  followed  by  Coze^  Feltz,  and  Davaine.  He 
injected  putrid  iluids,  decomposed  blood,  putrefying  blood,  under  the  skin 
in  mice.  He  found  that  the  virulence  of  these  fluids  was  attenuated  by  age. 
Blood  that  had  putrefied  only  for  a  few  days,  in  5-drop  doses,  killed  a  mouse 
within  a  short  time.  In  this  case  marked  symptoms  were  observed  in  the 
animal  immediately  after  the  injection. 

The  animal  became  very  restless,  running  about  constantly,  but  showing 
great  muscular  prostration  and  uncertainty  in  all  its  movements;  it  refused 
food,  the  respiration  became  irregular  and  slow,  and  death  took  place  within 
eight  hours.  The  greater  portion  of  the  fluid  injected  was  found,  after  death, 
not  to  have  been  absorbed.  No  inflammation  at  the  seat  of  injection.  No 
macroscopical  pathological  changes  were  found  in  any  of  the  internal  organs. 
Blood  taken  from  the  right  auricle  and  injected  into  another  mouse  produced 
no  symptoms.  No  bacteria  could  be  found  in  the  blood  or  any  of  the  internal 
organs.  Koch  concluded  that  death  was  not  caused  by  bacteria,  but  by  the 
introduction  into  the  circulation  of  a  preformed  poison  contained  in  the 
putrid  fluid,  as  when  smaller  doses  were  used  the  symptoms  of  intoxication 
were  less  marked,  and  when  the  quantity  was  reduced  to  1  drop  the  animal 
often  recovered  without  manifesting  any  morbid  symptoms.  About  one- 
third  of  the  animals  which  had  received  1  or  2  drops  of  the  fluid  subcutane- 
ously  remained  well  for  about  twenty-four  hours,  when  an  increased  secretion 
from  the  conjunctiva  was  observed;  at  the  same  time  the  animal  showed 
signs  of  great  muscular  weakness.  It  then  ceased  to  take  food;  its  respira- 
tions became  slower,  prostration  became  more  and  more  marked,  and  death 
came  on  almost  imperceptibly.  After  death  the  animal  remained  in  the  sit- 
ting posture  with  its  back  strongly  bent.  Death  occurred  in  from  forty  to 
sixty  hours  after  inoculation.  The  only  post-mortem  change  noticed  was  a 
slight  subcutaneous  oedema  at  the  point  of  injection,  and  this  was  not  con- 
stantly present. 

Koch  then  experimented  with  the  cedema-fluid  and  blood  of  mice  that 
had  died  of  sepsis,  ^Ao  drop  of  which  was  injected  into  another  mouse,  when 
exactly  the  same  symptoms  and  result  were  produced  in  the  latter  animal, 
after  the  same  lapse  of  time  and  in  the  same  order  as  in  the  former. 

From  this  second  animal  a  third  was  infected  in  like  manner,  with 
identical  results.  Successive  inoculations  proved  that  the  virus  could  be 
propagated  indefinitely  from  animal  to  animal  without  losing  its  virulence. 
He  could  communicate  the  dis'ease  with  certainty  by  passing  the  point  of 
a  scalpel,  which  had  been  in  contact  with  the  infected  blood,  over  a  small 
Avound  of  the  skin.  The  blood  of  the  animals  which  became  ill  after  injec- 
tion of  1  to  10  drops  of  putrefying  blood  was  found  to  contain,  as  a  rule,  dif- 
ferent varieties  of  bacteria  in  small  numbers,  micrococci,  and  large  and  small 


356 


PRINCIPLES    OF    SUEGEKY, 


bacilli.  If,  however,  it  died  after  inoculation  with  putrefying  or  septicasmic 
blood,  small  bacilli  alone  appeared  in  the  blood.  This  result  was  constant,  and 
the  bacilli  were  always  in  large  numbers.  These  bacilli  lie  singly  or  in  small 
groups  between  the  red  blood-corpuscles.  One  can  often  see  the  bacilli  in 
septicseniic  blood  attached  to  each  other  in  pairs,  either  in  straight  lines  or 


^^. 


^  '>/; 
",'-!i 


.1       ■    .\N^ 


■  /  ^,~/i 


'T9^ 


waU 
into 


'Q' 


Fig.  130.— Vein  of  the  Diaphragm  of  a  Septicaemic  Mouse.  A,  nuclei  of  the  vascular 
;  B,  septicaemic  bacilli;  O,  white  blood-corpuscles  which  have  become  transformed 
masses  of  bacilli;    D,  capillaries  opening  into  vein.     X  700.     {Kocli.)^ 


forming  an  obtuse  angle.  In  some  cases  Koch  has  also  seen  spores  in  the 
bacilli.  Their  relation  to  the  white  corpuscles  is  peculiar.  They  penetrate 
into  these  and  multiply  in  their  interior. 

1  Figs.  130,  132,  and  133  are  copied  from  "Traumatic  Infective  Diseases,"  by  permission 
of  the  New  Sydenham  Society,  London. 


BACTEEIOLOGICAL    EESEAECHES.  357 

Microscopical  examination  of  the  tissues  at  the  point  of  inoculation 
showed  that  the  bacilli  entered  the  capillar}^  hlood-vessels,  where  they  caused 
such  extensive  alterations  as  to  give  rise  to  extravasation  of  nnmerons  red 
blood-corpnscles.  They  were  never  found  in  the  lymphatic  vessels.  Within 
the  blood-vessels  they  are  almost  always  arranged  with  their  long  axis  in  the 
direction  of  the  blood-current.  In  the  capillaries  the  bacilli  congregate,  par- 
ticularly at  the  point  of  division,  but  never  cause  complete  obstruction. 
Eabbits  and  field-mice  proved  immune  to  inoculations  with  the  septicemic 
blood  of  the  domestic  mouse.  The  bacillus  of  Koch's  septicaemia  can  be 
cultivated  uj)on  a  mixture  of  aqueous  humor  and  gelatin,  or  of  gelatin,  pep- 
tone (1  per  cent.),  salt  (0.6  per  cent.),  and  sodium  phosphate  in  sufficient 
quantity  to  render  the  mass  alkaline  in  reaction.  The  bacilli  grow  well  upon 
this  mixture,  and  by  repeated  and  rapid  divisioii  form  peculiar  branched 
series. 

Septicsemia  in  Rabbits. — Although  Koch  was  unable  to  produce  sep- 
ticaemia in  rabbits,  either  by  injections  or  inoculations  of  septiesemic  prod- 
ucts from  the  domestic  mouse,  he  caused  the  disease  artificially  b}^  injecting 


Fig.  131. — Bacillus  of  Mouse-septicaBmia.     Single  Colony  in  Nutrient  Gelatin. 
X  80.     {Flilgge.) 

a  putrid  infusion  of  meat.  In  these  cases  the  injection  produced  extensive 
suppuration,  with  putrefaction,  and  the  animals  died  in  three  days  and  a 
half.  A^arious  bacteria  were  found  in  the  inflammatory  product.  At  the 
border  of  the  local  inflammation  the  connective  tissue  was  infiltrated  with  a 
turbid,  serous  fluid,  which  contrasted  strongly  with  the  brownish,  offensive 
pus.  In  this  oedema-fluid  only  cocci  of  an  oval  form  were  found.  In  the 
blood  similar  microbes  were  discovered,  though  only  in  small  numbers. 
Some  of  the  small  veins  in  the  spleen  and  kidneys  were  seen  to  be  com- 
pletely blocked  with  the  same  microbe. 

Two  drops  of  the  oedema-fluid  were  injected  under  the  skin  of  the  back 
of  a  second  rabbit.  The  animal  died  in  twenty-two  hours,  and  here,  in  the 
vicinity  of  the  injection,  not  a  trace  of  suppuration  could  be  found.  Hsemor- 
rhagic  extravasations  were  present  in  the  inflamed  oedematous  connective  tis- 
sue. Xo  alterations  were  found  in  the  heart  and  lungs.  In  this  animal  the 
oval  micrococci  were  alone  present  in  the  oedema-fluid.  Micrococci  were  also 
found  in  the  capillary  vessels  in  different  organs;  in  some  of  them  the  lumen 
of  the  vessels  was  completely  blocked.    In  the  capillary  vessels  surrounding 


358 


PRINCIPLES    OF    SUEGEEY. 


the  intestinal  glands  numerous  obstructing  masses  of  the  bacilli  were  pres- 
ent. At  many  points  these  were  so  extensive  that  branching  accumulations 
were  seen  consisting  entirely  of  these  organisms.  This  microbe  was  never 
seen  to  inclose  blood-corpuscles,  and,  as  they  did  not  cause  coagulation  of 
the  blood,  embolism  was  never  observed.  The  virulence  of  the  bacillus  was 
not  increased  by  successive  inoculation  with  infected  blood  from  animal  to 
animal. 


Fig.  132. — Glomerulus  of  a  Septicemic  Rabbit  A,  capillary  loop  -with  oval  micro- 
cocci spread  out  like  a  membrane,  B,  micrococci  deposited  on  the  walls  of  a  capillary 
vessel;  G,  loop  completely  filled  with  micrococci;  D,  individual  micrococci  in  a  capil- 
lary vessel  near  a  glomerulus.    X  700.    {Koch.) 


The  bacillus  now  under  consideration  appears  to  be  closely  allied  or 
identical  with  that  of  Davaine's  septicsemia,  which  was  first  produced  by  in- 
jecting rabbits  with  putrid  ox-blood.  The  two  diseases  are  distinguished  in 
that  Davaine's  septicssmia  is  easily  transmissible  to  guinea-pigs,  but  not  to 
birds;  while  mice,  pigeons,  fowls,  and  sparrows  are  very  susceptible  to  the 
bacillus  of  septicasmia  in  rabbits,  discovered  by  Koch,  but  guinea-pigs,  dogs, 
and  rats  resist.  Hueppe  believes  that  this  microbe  is  not  a  bacillus,  but  a 
coccus  in  a  state  of  elongation;   and  Gaffk)^  Schuetz,  Kitt,  Salmon,  Fliigge, 


BACTERIOLOGICAL    EESEAECHES. 


359 


and  Baumgarten  classify  it  with  the  bacilli.  It  readily  stains  in  aniline  solu- 
tions. Upon  sterilized  gelatin  it  grows  in  the  form  of  clear,  finely-granular 
drops,  which,  when  they  become  confluent,  form  a  culture  which  appears  as  a 
grayish-white  film  with  jagged  borders.  Liquefaction  of  the  gelatin  never 
takes  place.  It  can  also  be  cultivated  upon  agar-agar,  coagulated  blood- 
serum,  and  potato.  Gaffky  investigated  Davaine's  septicaemia  experiment- 
ally. He  procured  the  infection  by  using  water  from  a  stagnant  rivulet,  and, 
by  continually  controlling  the  experiments  with  the  microscope,  using  Koch's 
methods,  and  working  only  with  pure  cultures,  he  was  able  to  prove  beyond 


Fig.  133. — Capillary  Vessels  Surrounding  the  Intestinal  Glands  of  a 
Septicaemic  Rabbit.    X  700.    (Koch.) 


a  doubt  that  the  theories  of  progressive  virulence  of  bacteria  were  untenable. 
He  showed  that  the  highest  degree  of  virulence  was  already  attained  in  the 
second  generation.  He  pointed  out  that  the  fallacious  conclusions  were  due 
to  impurification  in  the  experiments,  and  that  when  the  proper  precautions 
are  taken,  in  the  process  of  sterilization,  to  prevent  the  admixture  of  other 
microorganisms,  the  introduction  of  one  kind  always  produces  in  the  same 
animal  the  same  definite  result. 

The  most  interesting  conclusions  to  be  drawn  from  the  experiments  in 
Koch's  laboratory  point  to  the  fact  that  septicsemia  is  only  a  general  term 
which  includes  a  number  of  morbid  processes,  and  this  is  well  illustrated  by 


360  PEINCIPLES    OP    SUEGEEY. 

the  injection  into  the  tissues  of  the  "vihriones  septiques"  of  Pasteur.  Surface 
inoculations  with  these  bacilli  produce  no  effect;  their  pathogenic  influence 
became  only  evident  after  injections  into  the  subcutaneous  connective  tissue. 
G-affky  found  that  this  bacillus  grows  most  readily  upon  potato.  Koch  ap- 
plied to  the  condition  produced  by  this  bacillus  the  term  "malignant 
cedema." 

Malignant  (Edema. — The  bacillus  of  malignant  oedema  was  described  by 
Koch  as  the  cause  of  a  fatal  disease  in  guinea-pigs  and  rabbits.  The  same 
bacillus  was  described  by  Pasteur  as  "vibrion  septique."  Eecently,  this  dis- 
ease has  been  found  also  in  some  of  the  domestic  mammalia  and  in  man. 
The  bacillus  resembles  morphologically  the  bacillus  anthracis. 

Usually,  two  or  three  bacilli  are  joined  end  to  end,  and  thus  form 
straight  or  curved  rods  two  or  three  times  the  length  of  one  bacillus.  When 
stained,  the  threads  present  a  granular  appearance,  from,  the  unequal  dis- 
tribution of  the  stainins:  material. 


^^ 


\ 


// 


S^f  ^ 


1/     0 

Fig.  134.  Fig.  135. 

Fig.  134. — Bacillus  of  Malignant  CEdenia.    A,  from  the  spleen  of  a  guinea-pig; 

B,  from  the  lung  of  a  mouse.     X  700.     {Koch.) 
Fig.  135.— Spore-formation  in  Bacillus  of  Malignant  CEdema.     (Fliigge.) 

This  bacillus  is  somewhat  narrower  than  the  anthrax  bacillus,  and  when 
stained  does  not  present  such  a  regular,  chain-like  appearance.  Sometimes 
the  bacillus  is  found  motile,  but  not  always,  while  the  anthrax  bacillus  is 
always  devoid  of  this  property.  It  multiplies  by  spores,  but  these  appear 
only  in  the  middle  and  at  the  ends. 

This  microbe  is  anaerobic,  and  can  only  be  cultivated  by  exclusion  of 
oxygen.  The  bacillus  can  only  grow  in  the  interior  of  agar-agar,  gelatin,  or 
coagulated  blood-serum,  if  the  needle-puncture  on  the  surface  of  the  nutrient 
medium  is  hermetically  sealed.  The  growth  of  the  bacillus  is  attended  by  the 
formation  of  gas-bubbles. 

The  gas  has  an  intensely  offensive  odor.  Blood-serum  is  liquefied.  The 
temperature  of  the  blood  is  most  favorable  to  the  growth  of  the  bacillus,  and 
cultures  develop  also,  but  slowly,  at  a  temperature  of  18°  to  30°  C. 

This  bacillus  is  widely  diffused,  and  can  be  found  in  almost  any  putre- 
fying substance.  The  bacillus  of  malignant  cedema  possesses  the  power  of 
peptonizing  albumen.    It  is  found  in  abundance  in  garden-earth  and  hay- 


BACTEEIOLOGIOAL    EESEAKOHES. 


361 


dust.  If  a  small  quantity  of  either  of  these  substances  is  inserted  underneath 
the  skin  of  a  guinea-pig,  death  is  produced  within  forty-eight  hours.  The 
most  characteristic  post-mortem  appearance  is  a  diffuse  oedema  at  the  point 
of  inoculation.  The  oedema-fluid  is  a  clear,  reddish  serum,  in  which  can  be 
found  bubbles  of  gas  and  numerous  bacilli.  The  spleen  is  enlarged,  of  a 
darker  color  than  normal,  but  the  other  organs  present  no  macroscopical 
changes.  The  bacilli  can  be  found  in  the  parenchyma-fluid  of  nearly  all 
organs,  and  especially  is  their  number  great  in  the  envelopes  of  the  infected 
organs.  Mice  die  in  from  sixteen  to  twenty  hours  after  inoculation.  Horses, 
sheep,  and  pigs  can  be  successfully  inoculated,  while  cattle  are  immune  to 
the  bacillus.  The  disease  can  be  communicated  from  animal  to  animal  by 
implantation  of  fragments  of  infected  tissue,  or  by  inoculation  with  1  or  3 
drops  of  the  cedema-fiuid.     Surface  inoculation  is  harmless,  as  the  bacillus 


Fig.  136.— Cultures  of  Bacillus  of  Malignant  CEdema  in  Gelatin.     (Flugge.) 


will  not  multiply  when  exposed  to  atmospheric  air.  In  man  malignant 
oedema  appears  in  the  form  of  progressive  gangrene  with  emphysema  {gan- 
grene gazeuse).  Eecently,  the  identity  of  this  disease  with  malignant  oedema 
has  been  proved  by  inoculation  experiments  by  Chaveau,  Arloing,  Brieger, 
and  Ehrlich.  Animals  which  have  recovered  from  an  attack  of  malignant 
oedema  remain  immune  to  this  disease,  but  prophylactic  inoculations  have  so 
far  yielded  only  negative  results.  Chaveau  made  many  experiments  on 
guinea-pigs,  sheep,  and  horses  by  injecting  the  liquid  contents  of  bullae 
which  he  found  in  cases  of  septic  gangrene.  In  doses  of  Vs  drop  in  guinea- 
pigs  and  from  2  to  4  drops  in  horses,  it  produced  death  in  a  short  time.  In 
all  cases  the  necropsy  shoAved,  at  the  point  of  injection,  localized  oedema  and 
turbid  serum  in  the  peritoneal,  pleural,  and  pericardial  cavities.  In  the  fluids 
the  bacillus  could  always  be  demonstrated  under  the  microscope.  The  disease 
could  be  reproduced  in  other  animals  by  inoculation  Avith  the  serous  fluid 


362  PRINCIPLES    OF    SUEGEEY. 

contained  in  any  of  the  serous  cavities.     The  microbe  proved  less  virulent 
when  injected  directly  into  the  circulation. 

Dominici  found  that  experimental  septicaemia  caused  nucleated  red 
blood-cells  to  appear  in  the  bone-marrow  of  the  infected  animals.  In  ex- 
amining the  bone-marrow  of  human  beings  the  subjects  of  septic  infection, 
he  found,  besides  myeloplaques  and  many  mononucleated  cells,  a  number 
of  red  blood-corpuscles  with  a  single  nucleus.  He  ascertained  that,  while 
their  occurrence  is  rare,  nucleated  corpuscles  do  appear  at  times  in  the  cir- 
culating blood  in  cases  of  septicsemia. 

PYOGENIC    MICEOBES    AS    A    CAUSE    OF    SEPSIS. 

The  general  symptoms  which  accompany  all  suppurative  affections  rep- 
resent, etiologically  and  clinically,  a  form  of  sepsis,  which  differs  in  its  in- 
tensity according  to  the  quantity  of  pus-microbes,  or  their  toxins,  which 
reach  the  general  circulation.  The  slight  fever  which  often  attends  the  de- 
velopment of  a  furuncle  ceases  with  the  removal  of  the  products  of  inflam- 
mation, while  a  septic  or  diffuse  suppurative  peritonitis  results  in  death  in  a 
short  time  from  septic  infection.  The  different  forms  of  suppurative  inflam- 
mation result  in  gangrene  if  the  disease  prove  fatal;  the  immediate  cause  of 
death  is  usually  septic  infection  or  putrid  intoxication.  Watson  Cheyne 
maintains  that  the  microbes  of  sepsis  only  grow  in  loco,  and  act  by  producing 
toxins,  or,  if  they  occur  in  the  blood,  they  do  not  make  emboli. 

Vidal  reported  to  the  Academie  de  Medecine  de  Paris  the  results  of  his 
studies  of  the  "forme  septicemique  pure"  in  puerperal  fever  of  typhoid  type 
without  suppuration.  In  all  of  the  cases  in  which  he  made  a  bacteriological 
examination  he  found  the  streptococcus  pyogenes,  and  from  this  and  the 
results  of  his  culture  and  inoculation  experiments  he  comes  to  the  conclusion 
that  it  is  impossible,  in  the  present  state  of  our  knowledge,  to  distinguish 
between  the  various  forms  of  streptococci,  and  that  one  and  the  same  kind 
can  set  up  any  of  the  various  forms  of  septic  infection.  Besser  has  examined 
32  cases  of  traumatic  sepsis,  and  found  microbes  of  suppuration  in  every  one 
of  them.  During  the  patient's  life  he  discovered  the  microbe  (a)  in  the  blood 
in  4  of  16  cases  examined;  (b)  in  the  pus  or  fluid  discharge  from  the  primary 
focus,  in  17  of  17;  (c)  in  the  urine,  in  3  of  4;  and  (d)  in  the  sputa,  in  3  of  3; 
while  after  death  the  microorganism  was  present  (a)  in  the  blood,  in  7  of  15; 
(&)  in  the  internal  organs,  in  16  of  18;  and  (c)  in  the  pus  or  uterine  dis- 
charges, in  12  of  12.  In  6  of  22  cases  pus-microbes  were  simultaneously  de- 
tected side  by  side  with  masses  of  bacteria  of  many  other  species.  In  3  cases, 
however,  the  streptococcus  was  found  alone,  unassociated  with  any  other  mi- 
crobe. Besser  is  of  the  opinion  that  the  streptococcus  of  suppuration  is  the 
most  frequent  cause  of  sepsis.  Smith  isolated  and  cultivated,  from  2  cases  of 
puerperal  sepsis,  a  streptococcus  which,  by  inoculation  and  cultivation  ex- 


CLINICAL    POEMS    OF    SEPTICEMIA.  363 

periments,  differed  from  the  streptococcus  of  Fehleisen  and  the  ordinary 
streptococcus  of  suppuration.  He  made  a  series  of  gelatin  cultures  with  blood 
taken  from  the  heart.  After  an  interval  of  two  or  three  days  numerous  colo- 
nies appeared.  Eats  inoculated  with  a  pure  culture  died  in  from  three  to  four 
days;  the  same  microbe  was  discovered  in  their  blood.  Inoculations  were 
also  made  in  the  ears  of  rabbits,  and  at  the  end  of  twenty-four  hours  a  circum- 
scribed redness  without  tendency  to  diffusion  was  apparent,  the  redness  dis- 
appearing in  two  or  three  days.  Another  series  of  cultures  and  inoculations 
was  made  with  blood  taken  from  the  finger  of  a  woman  sick  with  puerperal 
fever,  with  similar  results. 

From  these  considerations  it  hecomes  evident  that  the  essential  bacterial 
cause  of  septicoimia  is  variable,  and  that  the  disease  represents  a  general  febrile 
condition,  which  is  brought  about  by  the  absorption  from  a  local  focus  of  dif- 
ferent toxins  from  as  many  different  microbes.  As  the  introduction  into  the 
circulation  of  the  products  of  putrefaction  is  followed  by  a  complexus  of 
symptoms  which  closely  resemble  what  is  understood  clinically  by  the  term 
septicemia,  and  as  different  microbes  have  been  cultivated  from  septic  pa- 
tients, it  would  seem  that  this  disease  can  be  produced  by  any  of  the  microbes 
which,  after  their  introduction  into  the  organism,  have  the  capacity  to  multiply 
and  produce  a  sufficient  quantity  of  phlogistic  toxins  to  give  rise  to  septic  in- 
toxication. 

CLINICAL    PORMS    OP    SEPTICAEMIA. 

A  clinical  description  of  septicsemia  cannot  be  given  without  a  sub- 
division of  the  disease  upon  an  etiological  basis.  Since  the  publication  of 
Gaspard's  researches  it  is  absolutely  necessary  to  make  a  distinction  between 
septic  intoxication  and  septic  infection.  By  septic  intoxication  is  understood 
that  form  of  septicaemia  which  is  caused  by  the  absorption  from  a  local  focus 
of  a  ferment  or  the  products  of  putrefaction,  while  the  term  septic  infection 
is  limited  to  those  cases  where  septic  microorganisms  gain  entrance  into  the 
circulation,  and  not  only  exercise  their  pathogenic  properties  in  the  blood, 
but  retain  their  capacity  of  reproduction  in  the  circulation  and  distant  or- 
gans. Septic  intoxication  is  caused  by  the  absorption  of  a  preformed  ferment 
or  toxin,  which  produces  the  maximum  result  as  so'on  as  it  reaches  the  circula- 
tion, and  the  symptoms  subside  with  the  arrest  of  further  supply  and  the  elim- 
ination of  the  septic  material  from  the  circulation.  Septic  infection,  on  the 
other  hand,  occurs  in  consequence  of  the  introduction  into  the  circulation 
of  living  microorganisms  ivhich  multiply  ivith  great  rapidity  in  the  blood:  a 
circumstance  which  imparts  to  this  form  of  septiccemia  its  progressive  char- 
acter. Septic  intoxication  is  caused  either  by  the  absorption  of  fibrin- ferment 
or  the  products  of  putrefactive  bacteria. 

(a)   Fermentation  Fever. — Fermentation  fever  (Bergmann),  after-fever 


364:  PEINCIPLES    OF    SUEGEEY. 

(Billroth),  aseptic  fever  (Volkmann),  resorption  fever,  are  terms  used  to 
designate  a  general  febrile  disturbance  caused  by  the  absorption  of  the  prod- 
ucts of  aseptic  tissue-necrosis.  This,  the  most  simple  and  harmless  of  all 
wound  complications,  appears  as  a  temporar}^  fever  soon  after  an  injury  or 
operation,  and  is  caused  by  the  absorption  of  aseptic  phlogistic  substances. 
Different  aseptic  inert  substances,  when  injected  into  the  circulation,  are 
known  to  produce  a  rise  in  temperature.  Bergmann  witnessed  such  a  reac- 
tion after  intravenous  infusion  of  a  physiological  solution  of  salt;  Freese, 
after  transfusion  of  blood  of  healthy  animals;  and  Bergmann,  Strieker, 
Albert,  and  Billroth,  after  intravenous  injections  of  a  considerable  quantity 
of  well-water.  The  same  effect  is  produced  by  intravenous  injections  of 
water  in  which  fine  foreign  particles,  as  flour  or  finel3^-pulverized  charcoal, 
are  suspended.  Volkmann  and  Genzmer  observed  a  rise  in  temperature  in 
patients  soon  after  the  operation  was  completed  and  when  the  wound  re- 
mained aseptic  throughout,  and  hence  called  this  form  of  fever  aseptic  fever. 
These  authors  attribute  the  fever  to  the  reception  into  the  blood  of  dead  tis- 
sue-material. Bergmann  devised  the  term  fermentation  fever  upon  the 
theory  that  the  fever  is  caused  by  the  presence  of  fibrin  ferment  in  the  blood. 

Angerer  and  Edelberg  demonstrated  experimentally  that  this  fever 
occurs  after  transfusion,  if  the  blood  transfused  contain  fibrin-ferment. 
Schmiedeberg  attributed  the  fever  to  the  presence  of  another  blood-ferment 
which  he  discovered  and  which  he  called  "histozym."  Bergmann  and 
Angerer's  experimental  researches  show  that  a  fever  which  resembles  the 
fermentation  fever  alinost  to  perfection  can  be  artificially  produced  in  ani- 
mals by  intravenous  injections  of  pancreatin,  pepsin,  and  trypsin.  It  would 
appear  that  the  albuminoid  substances,  which  are  in  excess  in  the  blood, 
undergo  oxidation  by  the  action  of  a  ferment,  and  that  the  chemical  changes 
brought  about  in  this  manner  occasion  rise  in  temperature,  while  the  prod- 
ucts of  oxidation  are  eliminated  through  the  kidneys.  Eiedel  found,  in  many 
cases  of  simple  subcutaneous  fracture,  albumen  in  the  urine  during  the  first 
three  or  four  days,  and  the  urine  always  contained  brown  masses,  which  he 
regarded  as  products  of  the  red  blood-corpuscles.  W.  Muller  found  invari- 
ably, after  transfusion  of  blood,  a  considerable  increase  of  urates  in  the  urine. 
The  occurrence  of  fever  after  the  introduction  of  foreign  aseptic  substances 
into  the  circulation  can  only  be  explained  upon  the  supposition  that  they 
destroy  red  and  white  corpuscles  in  the  blood,  and  that  in  this  manner  fibrin- 
ferment,  the  cause  of  the  fever,  is  generated. 

Symptoms  and  Diagnosis. — Fermentation  fever  is  prone  to  follow  an 
operation  or  injury  if  antiseptic  solutions  are  allowed  to  remain  in  the  wound, 
thereby  causing  necrosis  of  the  superficial  tissues,  or  where,  after  closure  of 
the  wound,  parenchymatous  oozing  gives  rise  to  tension:  a  local  condition 
which  forces  the  products  of  coagulation-necrosis  into  the  circulation.     As 


CLINICAL    FORMS    OF    SEPTICAEMIA.  365 

not  all  extravasations  of  blood  give  rise  to  fever,  we  must  take  it  for  granted 
that  when  fever  is  not  produced  its  absence  is  owing  either  to  an  absence  of 
fibrin-ferment  or  the  existence  of  local  conditions  which  prevent  its  absorp- 
tion. From  my  own  observations  I  am  convinced  that  the  amount  of  ex- 
travasated  blood  holds  no  relation  whatever  to  the  frequency  of  its  occur- 
rence or  its  intensity.  A  small  extravasation  under  high  pressure  is  more 
frequently  the  cause  of  fermentation  fever  than  a  large  blood-clot  in  a  loca- 
tion less  favorable  to  the  absorption  of  fibrin-ferment.  Fermentation  fever 
makes  its  appearance  within  a  few  hours  after  an  injury  or  operation,  and, 
as  a  rule,  it  is  not  preceded  by  a  chill.  The  temperature  rapidly  reaches  its 
maximum,  which  varies  from  100°  to  104°  F.,  and  remains,  without  much 
variation,  in  the  vicinity  of  the  maximum  height,  to  drop  suddenly  to  nor- 
mal at  the  end  of  the  first  to  the  third  day.  The  pulse  is  correspondingly 
increased  in  frequency  during  the  febrile  attack.  The  sensorium  remains 
intact,  the  aj)petite  is  not  much  disturbed,  and  none  of  the  subjective  symp- 
toms are  proportionate  to  the  severity  of  the  febrile  disturbance.  Patients 
with  a  high  temperature  feel  so  well  that,  if  their  wounds  permit  it,  they 
will  insist  on  walking  around  and  will  attend  to  their  business,  contrary  to 
the  advice  of  the  attending  surgeon.  The  most  important  diagnostic  feat- 
ures of  fermentation  fever  are  its  early  onset  after.an  injury  or  operation,  and 
its  spontaneous  subsidence  in  from  one  to  three  da3^s.  As  the  disease  is  caused 
by  the  introduction  of  phlogistic  substances  from  a  local  focus,  and  propa- 
gated by  intravascular  chemical  changes,  it  is  uninfluenced  by  any  form  of 
ihedication.  The  fever  subsides  spontaneously  upon  cessation  of  the  primary 
cause,  and  with  the  elimination  through  the  kidneys  of  the  products  of  in- 
travascular chemical  changes.  As  the  remaining  forms  of  sepsis  usually  ap- 
pear at  a  time  when  fermentation  fever  has  run  its  course,  the  diflierential 
diagnosis  presents  no  great  difficulties. 

The  treatment  of  fermentation  fever  is  entirely  of  a  prophylactic  nature. 
The  prophylactic  measures  consist  in  a  careful  haamostasis,  and  in  cases 
where  parenchymatous  oozing,  from  the  nature  of  a  wound  or  the  anatomical 
structure  of  the  tissues,  is  to  be  expected,  the  prevention  of  the  accumulation 
of  the  primary  wound-secretion  by  efficient  drainage.  Fermentation  fever 
must  be  included  among  the  septic  diseases,  as  the  fibrin-ferment  acts  as  a 
toxic  substance  in  the  same  manner  as  the  toxins  elaborated  by  septic  mi- 
croorganisms. Future  research  may  yet  demonstrate  that  even  this,  the  most 
harmless  form  of  septicasmia,  is  not  an  aseptic  fever,  but  that  it  is  caused  by 
pathogenic  microorganisms,  either  too  few  in  number  or  not  of  sufficient 
potency  to  produce  the  graver  forms  of  the  disease. 

(b)  Saprsemia. — This  term  was  devised  by  Mathews  Duncan  to  include 
a  form  of  septicasmia  resulting  from  the  absorption  of  the  products  of  putre- 
faction.   Saprsemia  is  the  typical  form  of  septic  intoxication,  as  it  is  always 


366  PEINCIPLES    OF    SUKGEKY. 

caused  by  the  introduction  into  the  circulation  of  preformed  ptomaines 
elaborated  in  dead  tissues  by  putrefactive  bacteria.  It  is  closely  allied  to 
fermentation  f ever^  as  the  symptoms  are  never  intensified  after  the  removal 
of  the  primary  cause,  but,  as  a  rule,  subside  promptly  after  this  has  been 
accomplished.  As  saprsemia  never  occurs  without  putrefaction  of  necrosed 
tissue,  and  as  putrefaction  never  takes  place  without  infection  with  putre- 
factive bacteria,  it  becomes  necessary  to  consider  briefly  the  microorganisms 
which  are  known  to  cause  the  clinical  forms  of  putrefaction. 

Bacilli  of  Putrefaction.^ — The  bacilli  of  putrefaction  exercise  their 
pathogenic  qualities  only  in  dead  tissue  exposed  to  the  atmospheric  air. 
Clinically  they  are  therefore  present  in  the  products  of  coagulation-necrosis, 
or  as  a  secondary  infection  in  tissues  destroyed  by  other  microorganisms. 
Most  of  them  possess  gasogenic  properties.  Eosenbach  discovered,  in  differ- 
ent fetid  secretions,  three  forms  of  bacilli  which  he  designated,  respectivel}^, 
bacillus  saprogenes  1,  2,  3. 


Fig.  138.  Fig.  139. 

Figs.  137,  138,  and  139.— Bacillus  Saprogenes  1,  2,  3.    962:1.     {Rosenbach.) 

Bacillus  Saprogenes  1. — A  comparatively-large  bacillus,  which  multi- 
plies by  end-spores,  which,  however,  grow  only  from  one  end  of  the  bacillus. 

On  nutrient  agar-agar  the  bacillus  grows  in  the  form  of  an  irregular 
sinuous  streak,  with  a  mucilaginous  appearance.  The  bacilli  grow  readily 
also  in  blood-serum,  and  all  cultures  emit  the  odor  of  decomposing  kitchen 
refuse.  Albumen  pr  meat  acted  upon  by  a  culture  of  this  bacillus  undergoes 
rapid  putrefaction  if  exposed  to  atnxospheric  air,  but  if  air  is  excluded  the 
action  of  the  microbes  upon  these  substances  is  very  slight.  Cultures  injected 
into  healthy  tissues  and  Joints  are  harmless. 

Bacillus  Saprogenes  2. — This  bacillus  was  isolated  by  Eosenbach  from 
fetid  sweat.    The  rods  are  shorter  and  thinner  than  the  preceding  ones. 

This  bacillus  develops  very  rapidly  on  agar-agar,  forming  transparent 
drops,  which  become  gray.  The  culture  yields  a  characteristic  fetid  odor, 
similar  to  the  last.  Cultures  of  this  bacillus  injected  into  the  knee-joint  and 
pleural  cavity  of  rabbits  caused  acute  suppurative  inflammation  and  death. 

Bacillus  Saprogenes  3. — This  bacillus  was  discovered  by  Eosenbach  in 
the  pus  of  2  cases  of  osteomyelitis  with  septic  manifestations  complicating 
compound  fracture. 


CLINICAL    FOKMS    OF    SEPTICAEMIA.  ''  367 

Cultivated  on  nutrient  agar-agar,  an  ash-gray,  almost-liquid  culture  is 
developed,  with  a  strong,  characteristic  odor  of  putrefaction.  Injected  into 
the  knee-joint  or  abdomen  of  a  rabbit,  an  opaque,  yellowish-green  infiltration 
resulted. 

Proteus  Vulgaris. — This  and  the  following  species  have  been  described 
by  Hauser  as  present  in  putrefying  meat-infusions,  and  as  being  intimately 
connected  with  the  process  of  putrefaction.  As  the  name  indicates,  these 
bacteria  are  capable  of  changing  their  form  during  their  development.  The 
different  species  of  proteus  have  been  described  as  coccoid,  bacteroid,  spindle- 
shaped,  and  spiralinar,  on  account  of  the  ever-changing  form  they  assume 
during  their  growth.  The  morphology  of  the  proteus  vulgaris  is  very  vari- 
able. 


Fig.  140.— Proteus  Vulgaris.    285:1.     Swarming  Islets.     (Hauser.) 

Many  of  the  rods  are  actively  motile,  and  cultivated  upon  nutrient 
gelatin  they  convert  it  into  a  turbid,  grayish-white  liquid.  If  cultivated  in 
a  capsule  containing  5  per  cent,  of  nutrient  gelatin,  a  few  hours  after  inocula- 
tion, the  most  characteristic  movements  of  the  individual  bacilli  are  observed 
on  the  surface  of  the  gelatin,  although  at  this  early  stage  no  liquefaction  can 
be  detected.  The  movements  are  not  observed  if  the  nutrient  medium  con- 
tains 10  per  cent,  of  gelatin.  Spore-formation  was  never  observed.  Injected 
subcutaneously  in  small  doses,  no  results  were  obtained;  larger  doses  some- 
times caused  circumscribed  abscess  at  the  point  of  injection.  Intravenous 
injection  of  a  large  dose  produced  toxic  symptoms  in  rabbits  and  guinea-pigs, 
and  these  were  not  modified  by  using  the  filtrate  of  a  liquefied  culture,  show- 
ing that  the  toxic  substance  was  held  in  solution. 

Proteus  Mirabilis. — Eods  varying  greatly  in  length,  sometimes  so  short 
that  they  appear  like  cocci,  at  others  of  considerable  length. 


368 


PEINCIPLES    OF    SURGEEY. 


The  rods  occur  singly  and  in  zoogloea,  and  sometimes  in  tetrads,  pairs, 
chains,  or  as  short  rods  in  twos,  resembling  bacterium  termo;  in  fact,  in  all 
conceivable  transition-forms. 

Cultivated  on  nutrient  gelatin,  they  form  a  thick,  whitish  layer,  in  con- 
centric circles,  which,  in  time,  liquefies  the  medium.  Similar  movements  are 
observed  in  capsule-cultivations  as  with  proteus  vulgaris.  The  pathogenic 
properties  of  the  mirabilis  are  the  same  as  those  of  vulgaris. 

Proteus  Zenkeri. — Eods  about  four  times  as  long  as  wide,  in  twos,  like 
bacterium  termo.  Cultivated  on  nutrient  gelatin,  no  liquefaction  results,  but 
a  thick,  whitish-gray  layer  is  formed,  with  sloping  margins.  The  bacilli  are 
motile,  and  the  same  phenomena  are  observed  on  the  solid  medium  as  in  the 
other  forms.  Spirilli  and  spiralinar  forms  are  seldom  seen.  Gelatin  and 
blood-serum  cultures  emit  no  fetid  odor,  but  meat-infusion  undergoes  rapid 


Pig.  141.— Proteus  Mirabilis.     285:1.     Swarming  Islets.     (Hauser.) 

putrefaction  and  yields  the  usual  fetid  odor.  The  pathogenic  qualities  are 
the  same  as  those  of  the  other  species  of  proteus. 

As  the  microbes  of  putrefaction,  which  have  first  been  described,  pos- 
sess limited  or  no  pathogenic  qualities  when  introduced  into  healthy  tissue, 
it  is  evident  that  their  toxic  effect  is  caused  by  a  soluble  substance  which  they 
produce  when  they  find  their  way  into  dead  tissue  exposed  to  atmospheric 
air.    This  leads  us  to  a  consideration  of  the 

Ptomaines.  —  Ptomaine  is  a  term  used  to  designate  certain  toxic  sub- 
stances (resembling  alkaloids)  which  are  produced  during  the  process  of 
putrefaction.  Gautier  has  shown  that  in  dead  animal  tissues  processes  of 
putrefactive  decomposition  set  in,  by  which  certain  alkaloids  are  elaborated 
from  albuminous  substances,  which  have  been  called  ptomaines  by  Selmi. 


CLINICAL    FOEMS    OF    SEPTICEMIA. 


369 


In  the  latter  part  of  the  seventeenth  century  Kircher  and  Leeuwenhoek 
claimed  that  putrid  substances  contained  minute  microscopical  worms,  which 
caused  the  putrefaction.  In  1820  Kerner  pointed  out  the  resemblance  be- 
tween the  symptoms  of  poisoning  by  sausages  and  by  atropine.  He  was  thus 
the  first  to  raise  the  suspicion  that  toxic  alkaloids  were  formed  through  the 
decomposition  of  albumen.  In  1856  Panum  showed  that  the  inflammatory 
change  which  occurs  in  the  intestinal  mucous  membrane  of  animals  fed  on 
putrid  infusions  is  due  to  a  chemical  poison,  which  remained  unaffected  by 
boiling  for  a  long  time;  and  his  conclusion  that  the  toxic  substance  contained 
in  putrid  fluids  was  of  a  chemical  nature  was  confirmed  by  Weber,  Hemmer, 
Schweninger,  Stich,  and  Thiersch.  In  1875  B.  W.  Eichardson  isolated  a 
toxic  substance,  which  he  called  "septine,"  from  the  inflammatory  transuda- 
tion in  the  peritoneal  cavity  of  a  person  that  had  died  of  pygemia.  With  this 
substance  he  successfully  infected  animals.  He  also  found  that  this  sub- 
stance could  be  made  to  combine  with  acids,  so  as  to  form  salts,  without 
losing  its  toxic  qualities.    Bergmann  and  Schmiedeberg  isolated  a  crystalline 


Fig.  142.— Involution  Forms  of  Proteus  Mirabilis.     524  : 1.     (Hauser.) 

poison  from  decomposing  yeast,  to  which  they  gave  the  name  of  "sepsin." 
This  substance,  when  injected  into  the  subcutaneous  tissue  or  venous  circula- 
tion in  animals,  produced  well-marked  symptoms  of  septic  intoxication;  the 
intensity  of  the  symptoms  were  found  to  vary  with  the  amount  of  the  sub- 
stance injected.  Zuelzer  and  Sonnenschein  obtained,  from  macerated  dead 
bodies  and  from  putrid  meat-infusions,  small  quantities  of  a  crystallizable 
substance  which  exhibited  the  reactions  of  an  alkaloid,  and  had  a  ph5^sio- 
logical  action  like  atropine,  dilating  the  pupil,  paralyzing  the  muscular  fibres 
of  the  intestine,  and  increasing  the  rapidity  of  the  pulse.  In  1857  Pasteur 
made  the  important  discovery  that  specific  microorganisms  are  the  cause  of 
the  various  forms  of  fermentation  and  putrefaction.  No  discovery,  perhaps, 
attracted  such  universal  attention  as  Pasteur's  theory  of  fermentation.  This 
theory  was  strengthened  somewhat  later  by  Lemaire's  observation,  that  all 
fermentative  changes  in  fluids  are  suspended  on  the  addition  to  the  fluids  of 
phenic  acid,  from  which  he  concluded  that  fermentation  must  be  due  to 


370  PEIXCIPLES    OF    SURGERY. 

living  organisms.  Xext  came  the  carefully-conducted  experiments  of  Lister, 
who  showed  that  air  is  deprived  of  its  action  in  causing  putrefaction  of  or- 
ganic substances  if  it  is  passed  through  a  filter,  or  if  the  fluids  are  placed  in 
an  open  vessel  with  the  mouth  of  the  vessel  so. arranged  that  dust  cannot 
reach  the  fluid  by  gravitation. 

Lister's  great  life-work,  antiseptic  surgery,  that  has  created  a  new  epoch 
in  the  history  of  medicine  and  surgery,  is  based  upon  what  then  was  still  a 
theory,  that  inflammation,  suppuration,  and  septic  infection  of  wounds  are 
caused  by  living  specific  microorganisms.  Selmi  discovered  ptomaines  in  an 
exhumed  body,  in  1872.  The  ptomaines  isolated  by  him  were  volatile  alka- 
loids. Gautier,  independently  of  Selmi,  and  about  the  same  time,  made  the 
same  observations,  but  believed  that  the  toxic  substances  were  volatile,  and 
that  in  their  action  they  resembled  the  narcotics,  morphia  and  atropia,  and 
were  more  nearly  allied  to  the  alkaloid  extracted  from  poisonous  mushrooms. 

Semmer  gives  an  account  of  the  action  of  septic  substances  as  studied 
experimentally  by  Guttmann,  of  Dorpat.  The  experiments  were  made  with 
putrid  substances,  products  of  inflammation,  septic  blood,  and  cultivations 
of  septic  bacteria.  These  researches  showed  that  a  chemical  poison  is  formed 
in  putrefying  substances,  and  that  a  certain  quantity  of  such  poison  produces 
symptoms  of  sepsis  and  death  in  animals.  The  blood  of  animals  killed  with 
such  putrid  poisons  was  found  to  possess  no  infective  qualities,  and  the  usual 
putrefactive  bacteria  were  destroyed  in  the  blood,  and  only  appear  again 
after  the  death  of  the  animal.  It  was  claimed,  even  at  that  time,  that  the 
bacteria  elaborate  the  poison,  as  experiments  made  with  cultures  grown  out- 
side the  body  produced  the  same  effect.  Another  conclusion  arrived  at  was 
that  putrid  substances  administered  subcutaneously  may  produce  gangrene, 
phlegmonous  inflammation,  or  erysipelas,  according  to  the  stage  of  putrefac- 
tion, temperature,  culture-soil,  etc.  The  infective  material  was  never  found 
in  the  blood,  but  always  in  the  products  of  inflammation.  It  was  clearly 
stated  that  true  septicaemia  is  always  preceded  by  a  stage  of  incubation,  and 
that  its  contagium  is  destroyed  by  boiling,  putrefaction,  and  germicides. 

Bergmann  and  Angerer  produced  a  condition  in  animals  resembling 
septica?mia,  by  injecting  into  the  circulation  pepsin,  pancreatin,  and  trypsin. 
When  death  occurred  after  intravascular  injections  of  these  ferments,  fibri- 
nous deposits  were  found  in  the  heart  and  pulmonary  vessels.  These  experi- 
ments were,  therefore,  confirmatory  of  the  observations  previously  made  by, 
Edelberg  and  Birck,  who  had  shown  that  the  injection  of  putrid  substances 
into  the  circulation  materially  increased  the  free  fibrin-ferment  in  the  cir- 
culating blood. 

Blumberg  concluded,  from  his  numerous  experiments  on  animals,  that 
the  symptoms  which  follow  an  injection  of  putrescent  material  into  the  cir- 
culation are  not  always  constant;    that,  in  fact,  extreme  prostration,  high 


CLINICAL    FOBMS    OF    SEPTIC.FIMIA.  371 

temperature,  rapid  pulse  and  respiration  are  the  only  constant  symptoms 
found.  The  same  author  also  confirmed  the  statement  that  the  blood  of  pa- 
tients dying  from  putrid  intoxication  contained  no  microorganisms.  Sam- 
uel maintains  that  putrid  fluids,  from  the  second  day  until  the  eighth  month 
of  putrefaction,  act  differently,  and  divides  their  action  according  to  this 
supposition  into  three  stages:  1.  Phlogogenic,  in  which  they  produce  only 
inflammation.  3.  Septogenic,  in  which  they  produce  in  the  living  organism 
putrefactive  processes.  3.  Pyogenic,  in  which  they  cause  only  suppuration, 
having  lost,  in  the  meantime,  their  other  pathogenic  qualities. 

Mikulicz  found  that  putrid  fluids,  according  as  they  are  free  from  bac- 
teria or  contain  more  or  less  of  jDutrefactive  microbes,  will  produce  a  slight 
inflammation,  a  suppurative  inflammation,  or  a  progressive  phlegmonous  in- 
flammation. Frankel  detected  but  few  micrococci  in  the  blood  of  septicsemic 
patients,  and  observed  that  they  greatly  increased  after  death;  but,  after  the 
lapse  of  some  further  time,  altogether  disappeared,  thus  also  confirming  a 
fact  previously  known,  that  putrefaction  destroyed  septic  microbes.  These 
observations  may  tend  to  harmonize  the  discrepancy  of  opinion,  growing  out 
of  the  different  results  obtained  by  different  experimenters,  by  injections  of 
putrid  substances,  as  some  of  the  fluids  may  have  contained  an  abundance 
of  living  microorganisms,  while  others  may  have  been  rendered  sterile  by  age, 
owing  to  advanced  putrefactive  changes.  Brieger  and  Maas  have  rendered 
valuable  service  in  the  chemical  isolation  of  ptomaines,  or,  as  Brieger  calls 
them,  toxins,  from  putrid  substances,  and  the  results  of  their  inoculation 
experiments  established  more  firmly  the  fact  of  putrid  intoxication  by  these 
soluble  alkaloid  substances.  The  number  of  bacteria  in  rabbits  killed  by 
septic  infection  is  so  great  that  death  may  ensue  from  simple  mechanical 
causes,  while  in  fatal  cases  of  sepsis  in  man  the  number  is  often  so  small  that 
it  seems  natural  to  suppose  that  the  microorganisms  are  capable  of  producing 
some  poisonous  substance,  which  destroys  the  patient  before  they  have  time 
to  multiply  to  the  extent  observed  in  septicasmia  in  rabbits  and  mice. 

Einne  asserts  that  the  chemical  products  of  pus-microbes  alone,  as  well 
as  sterilized  putrid  fluids,  never  produce  metastasis.  He  sterilized  fluid 
cultures  of  the  staphylococcus  pyogenes  aureus  after  flltration,  and  injected 
directly  into  the  blood-vessels  of  rabbits  as  much  as  4  grammes  of  this  fluid, 
and  in  dogs  increased  the  dose  to  14  grammes.  Many  of  the  animals  showed 
slight  s3anptoms  of  septic  intoxication,  somnolence,  diarrhoea,  and  collapse. 
By  using  still  larger  doses  the  S3^mptoms  were  intesified  and  the  animals  died 
from  well-marked  symptoms  of  septic  intoxication.  Metastatic  abscesses 
were  never  found  in  these  cases.  The  same  author  has  also  published  some 
very  interesting  observations  on  the  immediate  cause  of  death  in  rabbits 
inoculated  with  a  pure  culture  of  Koch-Gaflky^s  bacillus.  The  animals  were 
inoculated  at  the  base  of  the  ear,  and  immediately  after  death  the  ptomaines 


372  PKINCIPLES    OF    SURGERY. 

were  isolated  from  the  tissues  by  Brieger's  method.  In  every  instance  he 
obtained  a  substance  called  methylguanidin,  which  on  chemical  analysis  was 
shown  to  consist  of  the  formula  C2H7N3.  When  this  substance  was  injected 
into  rabbits  it  produced  symptoms  of  septic  intoxication  which  resembled^, 
in  every  particular,  those  produced  by  the  injection  of  pure  cultures  obtained 
from  septicsemic  rabbits.  As  methylguanidin  could  not  be  produced  from 
the  cadavers  by  the  same  method,  Hoffa  naturally  came  to  the  conclusion 
that  it  was  a  product  of  the  bacilli,  and  that  death  was  to  be  attributed  to  the 
production  of  this  toxic  substance  in  the  tissues  of  the  infected  animals  by 
the  specific  action  of  the  bacilli.  The  source  of  methylguanidin  in  the  body 
is  creatin,  and  the  bacteria  must  possess  the  property  of  oxidation,  as  creatin 
is  transformed  into  methylguanidin  only  by  oxidation.  Brieger  has  isolated 
from  human  corpses  a  different  set  of  toxic  alkaloids,  one  of  which  he  calls 
"cadaverin"  and  the  other  "putrescin,"  which  are  but  feeble  poisons;  while 
two  others,  "madeline"  and  "sepsin,"  which  are  produced  later  on  in  the 
decomposition,  are  much  more  powerful  poisons,  causing  paralysis  and  death. 
Prom  decomposing  albuminous  substances  he  has  obtained  many  other  well- 
defined  chemical  bodies,  as  well  as  some  substances  to  which  no  names  have 
yet  been  given. 

Bourget  isolated  several  toxic  bases  from  the  viscera  of  a  woman  who 
had  died  of  puerperal  sepsis.  He  also  obtained  from  the  urine  of  patients 
suffering  from  the  same  disease  similar  toxic  bases,  which  killed  frogs  and 
guinea-pigs,  when  administered  by  injection,  showing  that  the  toxic  sub- 
stances formed  during  life,  and  that  they  are  eliminated  through  the  kidneys. 

The  experimental  and  clinical  researches  to  which  I  have  referred  above 
show  conclusively  that  septic  intoxication  is  caused  hy  the  presence  of  dead 
tissue  in  the  body  in  a  state  of  putrefaction,  from  the  presence  of  putrefactive 
bacilli,  and  that  the  immediate  cause  of  the  intoxication  is  the  absorption  'of 
preformed  ptomaines  from  such  a  local  focus  of  putrefaction. 

Symptoms  and  Diagnosis. — Septic  intoxication  sufficient  in  severity  to 
give  rise  to  grave  general  disturbances  is  usiially  initiated  by  a  chill,  or  at 
least  by  a  sensation  of  chilliness,  followed  by  a  continued  form  of  fever,  the 
temperature  rapidly  increasing  to  102°  to  104°  F.,  with  slight  morning  re- 
missions. The  character  of  the  pulse  furnishes  the  most  reliable  information 
in  regard  to  the  intensity  of  the  intoxication.  All  ptomaines  of  putrefactive 
bacteria  exert  a  depressing  influence  on  the  heart;  hence  the  force  and  fre- 
quency of  the  pulse  furnish  important  diagnostic  and  prognostic  evidences. 
The  pulse  is  always  soft  and  compressible:  qualities  which  indicate  dimin- 
ished intravascular  pressure,  resulting  from  an  enfeebled  vis  a  tergo.  Com- 
plete loss  of  appetite,  vomiting,  and  diarrhoea  are  almost  constant  symptoms 
in  grave  cases.  The  tongue  is  usually  furred,  dry,  and,  in  severe  cases,  pre- 
sents the  "dried-beef"  appearance.     The  urine  is  scanty  and  heavily  loaded 


CLINICAL    FOEMS    OF    SEPTICEMIA.  373 

with  urates.  Headache  is  often  complained  of  in  the  beginning  of  the  at- 
tack. Delirium,  restlessness,  insomnia,  are  symptoms  which  denote  ap- 
proaching danger.  Snhsultus,  dilatation  of  pupils,  clammy  perspiration, 
livid  appearance  of  visible  mucous  membranes,  low-muttering  delirium,  in- 
voluntary discharges,  coldness  of  the  extremities,  fluttering,  and  feeble  pulse 
precede  death  from  septic  intoxication.  One  of  the  most  important  elements 
in  the  diagnosis  is  the  detection  of  a  local  focus  of  putrefaction.  As  the 
putrefaction  always  occurs  in  parts  of  the  body  exposed  to  the  atmospheric 
air,  its  existence  can  readily  be  ascertained  by  the  sense  of  smell.  The  in- 
tensity of  the  foetor  of  the  gases  produced  by  the  putrefactive  bacteria  varies 
greatly,  but  the  smell  is  always  suggestive  of  decomposing  meat  or  kitchen 
refuse.  The  impression  is  quite  prevalent,  not  only  among  the  laity,  but  also 
in  the  profession,  that  the  local  lesions  which  cause  septicaemia  always  emit 
a  fetid  odor.  TJiis  is  a  grave  mistake.  Fator  is  associated  ivith  putrefaction, 
and  as  such  is  suggestive  of  saprcemia,  and  not  true  progressive  sepsis.  The 
latter  may  be  combined  with  saprsemia,  but  when  it  occurs  independently 
of  this  no  bad  smell  can  be  detected,  and  yet  it  is  the  most  fatal  form  of  sep- 
sis. In  reference  to  the  differential  diagnosis  between  saprsemia,  fermenta- 
tion fever,  and  septic  infection,  it  must  be  rememberd  that  septic  intoxica- 
tion can  only  occur  from  putrefaction,  and  therefore  three  conditions  must 
invariably  be  present  in  the  etiology  of  this  form  of  sepsis:  1.  Dead  tissue. 
2.  Infection  of  this  dead  tissue  with  putrefactive  bacteria.  3.  A  sufficient 
length  of  time  must  have  elapsed  since  the  injury  or  operation  for  the  putre- 
factive bacteria  to  produce  a  toxic  quantity  of  ptomaines  to  cause  s3^mptoms 
of  intoxication.  The  dead  tissue  may  be  a  blood-clot  in  a  wound,  around  the 
fragments  of  a  compound  fracture,  or  in  the  interior  of  the  uterus;  it  may  be 
tissue  devitalized  by  a  trauma,  heat  or  cold,  the  action  of  chemical  substances, 
or  the  action  of  bacteria  other  than  putrefactive;  or  it  may  be  detached,  re- 
tained fragments  of  placental  tissue.  That  such  dead  tissue  has  become  the 
.  seat  of  infection  with  putrefactive  bacteria  can  be  ascertained  by  the  presence 
of  foetor  and  bubbles  of  gas.  At  the  temperature  of  the  body  putrefaction 
progresses  very  rapidly;  but  a  differential  diagnosis  can  generally  be  made 
without  much  difficulty,  between  saprsemia  and  fermentation  fever,  by  the 
time  which  has  elapsed  between  the  injury  or  operation  and  the  manifesta- 
tion of  the  first  symptoms  of  septic  intoxication.  Fermentation  fever  ap- 
pears within  a  few  hours,  certainly  always  before  the  end  of  the  first  day, 
while  septic  intoxication  from  putrefaction  seldom  begins  before  the  ex- 
piration of  twenty-four  hours.  If  septic  infection  begin  during  this  time  it 
is  not  attended  by  any  evidences  of  putrefaction. 

Prognosis. — Uncomplicated  saprsemia  proves  fatal  by  the  absorption  of 
a  deadly  dose  of  ptomaines  from  a  local  depot  of  putrefaction,  and  the  prog- 
nosis will  therefore  depend  upon  the  stage  of  intoxication  and  the  feasibility 


374  PEINCIPLES    OF    SUEGEEY, 

of  the  removal  of  the  infected  dead  tissue  by  surgical  treatment.  If  an  effi- 
cient, radical  treatment  can  be  institiited  at  a  time  before  a  fatal  dose  of 
toxic  substances  has  reached  the  general  circulation,  the  prognosis  is  favor- 
able. A  decomposing  blood-clot  or  detached  fragment  of  a  placenta  can  be 
readily  removed  and  the  field  of  operation  sterilized.  The  prognosis  in 
saprsemia  complicating  jDrogressive  gangrene  is  always  grave,  as  the  dead 
tissue  is  increased  by  other  microbes;  hence  the  conditions  created  by  both 
kinds  of  microbes  are  of  a  progressive  character. 

Treatment. — The  prophylactic  treatment  of  saprsemia  consists  in  the 
removal  of  dead  tissue,  prevention  of  subsequent  extravasation  and  accumu- 
lation of  blood  by  careful  hsemostasis, — if  necessar}^,   by  drainage, — and 
finally  sterilization,  by  antiseptic  measures,  of  dead  tissue  that  cannot  be 
removed.    lodoformization  of  dead  tissue  is  an  excellent  means  of  preserva- 
tion.   In  the  extraperitoneal  treatment  of  the  stump  after  supravaginal  ex- 
tirpation of  the  uterus,  the  same  object  is  accomplished  by  touching  the  raw 
surface  with  a  solution  of  perchloride  or  persulphate  of  iron  or  pure  carbolic 
acid.     Wounds  in  which  dead  tissue  is  unavoidably  retained  should  always 
be  treated  by  drainage.    After  symptoms  of  septic  intoxication  have  devel- 
oped early,  radical  treatment  must  be  pursued.     This  treatment  comprises 
the  removal  or  sterilization  of  the  dead  tissue.    A  decomposing  blood-clot  is 
to  be  removed  and  the  parts  are  thoroughly  irrigated  with  a  solution  of  cor- 
rosive sublimate,  and  reaccumulation  prevented  by  efficient  drainage.     In 
cases  of  gangrene  complicated  by  putrid  intoxication,  where  it  is  impossible 
to  remove  the  infected  tissues  by  mechanical  measures,  and  complete  disin- 
fection without  such  a  procedure  cannot  be  effected,  the  best  results  are 
obtained  by  permanent  irrigation  with  a  saturated  solution  of  acetate  of 
aluminum.     Under  this  treatment  the  soluble  toxic  substances  are  washed 
away  as  fast  as  they  are  formed,  and  sterilization  of  the  soil  for  the  putre- 
factive bacteria  is  gradually  accomplished  by  the  saturation  of  the  dead  tis- 
sue with  this  safe  and  efficient  antiseptic  solution.    If  a  suppurating  cavity 
is  the  seat  of  putrefactive  changes,  it  becomes  necessary  to  remove  the  nu- 
trient medium  for  putrefactive  bacteria  by  first  washing  out  the  cavity  with 
a  strong  antiseptic  solution,  to  be  followed  by  the  mechanical  removal  of 
dead  tissue,  shreds  of  connective  tissue,  dead  granulations,  etc.,  by  means  of 
a  sharp  spoon  or  dull  curette,  and  subsequently  by  another  antiseptic  irri- 
gation.   The  surgical  treatment  of  saprEemia  will  soon  decide  the  fate  of  the 
patient.     If  a  fatal  dose  of  ptomaines  has  reached  the  general  circulation 
before  an  effort  is  made  to  procure  sterilization  of  a  local  depot  of  putrefac- 
tion, the  local  treatment  will,  of  course,  prove  unsuccessful  in  preventing  a 
fatal  result,  and  the  disease  will  continue  its  relentless  course  uninfluenced 
by  the  treatment.     If,  however,  the  intoxication  has  not  progressed  to  this 
extent,  efficient  local  treatment  is  followed  by  the  most  brilliant  results. 


CLINICAL    FOEMS    OF    SEPTICEMIA.  375 

Within  a  few  hours  after  the  sterilization  of  the  local  focus  of  putrefaction 
the  temperature  falls  to  normal,  the  pulse  becomes  slower  and  fuller.  If  the 
tongue  has  been  dry  it  soon  becomes  moist;  if  the  patient  has  been  delirious 
consciousness  returns,  and  the  patient  is  convalescent  in  a  few  days.  The 
results  of  the  antiseptic  local  treatment  in  these  cases  are  in  strong  contrast 
with  the  useless  and  often  dangerous  internal  administration  of  antipyretics. 
The  treatment  directed  toward  the  disinfection  of  the  local  focus  of  putre- 
faction removes  the  cause  of  the  intoxication,  while  the  antipyretics  may 
effect  a  temporary  reduction  of  the  temperature,  but  at  the  same  time,  by 
diminishing  the  contractile  power  of  the  heart,  only  add  to  the  danger  by 
diminishing  the  resistance  to  the  action  of  a  depressing  poison.  The  use  of 
antipyretics  in  the  treatment  of  saprgemia  is  strongly  contrainclicated.  All 
debilitating  treatment  must  be  carefully  avoided  as  being  unscientific  and 
as  adding  to  the  existing  dangers.  The  best  results  are  obtained  by  such 
local  treatment  by  which  the  further  production  of  ptomaines  is  prevented; 
consequently  5y  measures  luhich  meet  the  etiological  indications.  The  debili- 
tating effects  of  the  ptomaines  on  the  heart  are  met  by  the  timely  and  Judi- 
cious administration  of  stimulants.  In  urgent  cases  such  diffusible  stimu- 
lants as  sulphuric  ether,  camphor,  and  musk  can  be  administered  with  ad- 
vantage subcutaneously,  in  order  to  gain  time  for  the  action  of  remedies 
which  will  have  a  more  permanent  effect  on  the  heart.  Digitalis,  strophan- 
thus,  strychnia,  and  atropia  in  small  doses  are  excellent  cardiac  tonics  and 
stimulants,  and  are  indicated  in  cases  where  the  pulse  is  very  rapid  and  soft, 
denoting  a  feeble  peripheral  circulation  from  a  weakened  heart.  Where  life 
is  threatened  from  syncope  the  patient  is  not  allowed  to  assume  a  sitting 
position,  for  fear  that  the  increased  intracardiac  pressure  might  result  in 
sudden  death  from  heart-failure. 

Alcoholic  stimulants  are  to  be  given  in  doses  sufficiently  large  to  im- 
prove the  character  of  the  pulse,  and  at  sufficiently  short  intervals  to  main- 
tain this  effect  without  interruption.  Brandy  or  whisky,  in  doses  of  an  ounce 
every  two  hours,  diluted  with  water,  are  most  to  be  relied  upon;  but  cham- 
pagne, Grreek  sherry,  or  Eeich's  Tokayer  are  excellent  substitutes.  If  the 
stomach  is  irritable  or  the  symptoms  are  less  urgent,  concentrated  liquid 
food,  like  beef-tea,  milk,  and  eggnog,  must  be  given  at  regular  intervals  to 
assist  the  action  of  stimulants  in  sustaining  the  heart's  action  until  sufficient 
time  has  been  gained  for  the  elimination  of  the  ptomaines. 

(c)  Progressive  Septicsemia.- — This  is  the  septic  infection  of  modern 
authors,  and  differs  from  septic  intoxication  in  that  it  is  caused  not  by  putre- 
factive bacteria,  but  by  microbes  which  enter  the  circulation  from  some  local 
septic  focus,  and  which  retain  their  capacity,  of  reproduction  in  the  blood. 
It  is  called  progressive  sepsis,  because,  only  too  often,  it  is  not  followed  by 
any  abatement  of  the  symptoms,  as  the  essential  cause  has  passed  beyond  the 


376  PRINCIPLES    OF    SURGERY. 

reach  of  any  local  treatment^  and  goes  on  increasing  in  the  blood  until  it 
destroys  the  patient.  The  intoxication  in  this  form  of  sepsis  is  not  only  caused 
hy  toxins  which  are  produced  at  the  primary  seat  of  infection,  lut  toxins  are 
also  produced  in  the  blood  by  the  microbes  which  it  contains. 

True  progressive  sepsis  is  caused  by  the  introduction  of  septic  microor- 
ganisms into  the  tissues,  where  they  multiply  and,  later,  reach  the  blood, 
where  mural  implantation  and  capillary  thrombosis  take  place,  which  di- 
rectly interfere  with  the  proper  nutrition  and  function  of  important  organs, 
and  where  the  septic  intoxication  is  caused  by  the  formation  of  toxins,  both 
in  the  blood  and  living  tissues.  For  this  form  of  sepsis  Keelsen  has  suggested 
the  name  of  "acute  mycosis  of  the  blood,"  to  distinguish  it  from  putrid 
intoxication,  which  we  have  just  described,  and  which  Keelsen  calls  "toxic 
mycosis  of  the  blood,"  in  which  few  or  no  microbes  are  found  in  the  blood, 
and  in  which  death  is  due  exclusively  to  the  absorption  of  preformed  toxic 
substances  from  a  putrefying  depot. 

Causes. — Klebs  discovered  and  described  a  microbe,  the  microsporon 
septicum,  which  he  believed  was  the  specific  cause  of  septic  processes,  but 
recent  researches  seem  to  prove  that  the  pus-microbes  are  the  most  frequent 
cause  of  progressive  sepsis.  The  pus-microbes  either  reach  the  circulation 
directly  by  permeating  the  vessel-wall,  or  they  enter  by  a  more  indirect  route, 
through  the  lymphatic  channels.  The  latter  mode  of  infection  gives  rise  to 
the  most  acute  and  fatal  form  of  sepsis.  In  many  cases  of  septic  infection 
the  presence  of  lymphangitis  can  be  demonstrated  during  life,  and  by  exam- 
ination after  death.  A  few  years  ago  Bergmann  advanced  the  theory  that 
in  septicsemia.  microorganisms  enter  the  colorless  blood-corpuscles,  and  by 
multiplication  within  them  cause  their  dissolution,  a  process  during  which 
the  fibrin-generators  are  elaborated:  an  occurrence  ending  in  intravascular 
coagulation  and  capillary  embolism.  In  Koch's  septicemia  in  mice  such  a 
chain  of  pathological  conditions  can  be  readily  demonstrated;  but  in  many 
cases  of  fatal  sepsis  in  man  the  microbes  found  in  the  blood  are  few,  no  de- 
struction of  leucocytes  can  be  shown  to  have  occurred,  and  extravasations  and 
capillary  embolism  are  absent;  hence  death  cannot  be  attributed  to  fibrin 
intoxication.  In  such  instances  toe  can  only  assume  the  presence  of  a  soluble 
toxin,  which  is  diffused  throughout  the  entire  body  and  destroys  life  by  its  toxic 
properties.  The  formation  of  pus  at  the  primary  seat  of  infection  is  not 
necessary  in  the  causation  of  septicsemia  by  pus-microbes.  Septic  infection 
is  as  liable  to  take  place  from  wounds  that  do  not  suppurate  as  from  suppurat- 
ing wounds.  Why  a  wound  infected  with  pus-microbes  should  give  rise  to 
progressive  sepsis  in  one  individual,  and  suppuration  or  suppuration  and 
pyemia  in  another,  does  not  admit  of  a  satisfactory  explanation  at  the  pres- 
ent time. 

Einne  has  shown  that  diminution  of  the  absorptive  capacity  of  the  tis- 


CLINICAL    FOEMS    OF    SEPTICAEMIA.  377 

sues  at  the  seat  of  infection  plays  an  important  part  in  the  development  of 
septic  processes.  If  the  pus-microbes  are  rapidly  absorbed,  destroyed  in  the 
blood,  or  removed  by  elimination,  septic  inflammation  is  prevented.  If,  on 
the  other  hand,  the  local  conditions  are  such  that  the  microbes  remain  in  the 
tissues,  and  by  their  rapid  multiplication  produce  a  large  amount  of  soluble 
toxins,  which,  when  they  reach  the  blood,  not  only  produce  intoxication,  but 
prepare  the  blood  and  tissues  for  the  localization  and  reproduction  of  the 
microbes  at  points  distant  from  the  primary  seat  of  the  infection,  the  pathog- 
enic effect  of  the  microbes  on  the  tissues  at  the  primary  seat  of  infection  di- 
minishes their  power  of  resistance,  and  the  microbes  either  enter  the  blood- 
vessels directly  or  through  the  lymphatics.  Experimentally  it  has  been 
shown  that  if  a  large  quantity  of  pus-microbes  is  introduced  into  the  peri- 
toneal cavity,  or  directly  into  the  circulation,  death  results  from  sepsis  before 
a  sufficient  length  of  time  has  elapsed  for  the  pus-microbes  to  produce  the 
histological  changes  which  are  necessary  for  the  production  of  pus.  These 
experiments  a7-e  strongly  suggestive  of  the  fact  that,  in  man,  infection  ivith  pus- 
microhes  causes  progressive  sepsis,  if  a  large  quantity  of  pus-micrdbes  is  intro- 
duced into  tissues  debilitated  by  a  trauma,  antecedent  pathological  conditions, 
or  the  action  of  preformed  toxins.  Under  such  circumstances  the  pus-mi- 
crobes are  reproduced  with  great  rapidity  at  the  primary  focus  of  infection, 
enter  the  circulation  before  suppuration  has  had  time  to  develop,  and  pro- 
duce a  complexus  of  symptoms  and  a  series  of  pathological  changes  charac- 
teristic of  progressive  sepsis. 

Symptoms  and  Diagnosis. — The  most  typical  clinical  picture  of  progress- 
ive sepsis  is  produced  in  cases  of  septic  peritonitis,  dissection  wounds,  puer- 
peral septicaemia,  and  acute  multiple  osteomyelitis.  In  septic  peritonitis, 
after  laparotomy  or  penetrating  wounds  of  the  abdomen,  the  septic  inflam- 
mation, as  a  rule,  develops  within  the  first  forty-eight  hours,  and  with  it  the 
characteristic  symptoms  of  septicgemia  appear.  In  puerperal  sepsis  and  the 
gravest  form  of  acute  suppurative  osteomyelitis,  the  septic  symptoms  often 
overshadow  the  primary  disease  to  such  an  extent  that  this  is  entirely  over- 
looked. Dissection  wounds  often  prove  fatal  from  septic  infection,  which 
spreads  from  the  wound  along  the  course  of  the  lymphatic  vessels,  and  finally 
becomes  general  through  the  medium  of  the  circulation.  Septic  infection 
from  an  accidental  or  operative  wound  can  take  place  within  twenty-four 
hours,  and  seldom  occurs  later  than  the  third  or  fourth  day,  unless  the  infec- 
tion has  taken  place  after  the  first  dressing.  Like  all  other  acute  infectious 
processes,  septiceemia  is  ushered  in  by  a  more  or  less  pronounced  chill,  or  at 
least  a  subjective  sensation  of  chilliness,  which  may  be  repeated  during  the 
first  twenty-four  hours.  The  chill  is  never  so  pronounced  as  in  pyaemia,  and 
does  not  return  with  the  same  regularity  and  intensity  as  in  that  affection. 
The  chill  announces  the  termination  of  the  period  of  incubation,  and  is 


378  PRINCIPLES    OF    SUEGERY. 

promptly  followed  by  symptoms  of  reaction  which,  in  their  severity,  are  pro- 
portionate to  the  intensity  and  gravity  of  the  attack.  One  of  the  most  promi- 
nent features  of  the  disease  is  a  profound  prostration,  which  may  be  well 
marked  a  few  hours  after  the  beginning  of  the  attack.  If  septicsemia  follow 
an  operation,  or  a  severe  accident,  it  is  sometimes  almost  impossible  to  decide 
whether  the  pronounced  loss  of  strength  should  be  attributed  to  shock,  haem- 
orrhage, the  use  of  an  anaesthetic,  or  the  beginning  of  an  attack  of  septicae- 
mia. One  of  the  most  delusive  symptoms  is  the  utter  indifference  of  the 
patient,  not  only  as  to  his  own  grave  condition,  but  to  all  of  his  surround- 
ings. This  apathy  is  a  characteristic  symptom  of  profound  septic  intoxica- 
tion. The  patient  complains  of  no  pain,  assures  the  physician  and  friends 
that  he  is  feeling  well,  shows  absolutely  no  anxiety  concerning  his  own  fate, 
and  does  not  comprehend  the  anxiety  of  those  around  him.  Drowsiness, 
bordering  almost  on  stupor,  is  frequently  observed.  The  face  presents  a  pale 
or  ashy-gray  color,  and  in  advanced  cases  it  presents  a  yellowish,  icteric  tint, 
but  the  sclerotics  always  retain  their  white  color.  In  the  beginning  of  the 
attack  the  pulse  ranges  between  80  and  90,  but  becomes  rapid,  small,  and 
compressible  as  the  intoxication  and  capillary  obstruction  progress.  The 
character  of  the  pulse  is  of  great  diagnostic  and  prognostic  importance.  If 
the  pulse  within  a  short  time  reach  a  frequency  of  140,  and  impart  the  sensa- 
tion as  though  the  artery  were  only  half-filled  with  blood,  it  is  a  symptom 
which  forebodes  immediate  danger.  The  temperature  is  variable.  A  sub- 
normal temperature,  with  a  rapid,  feeble  pulse,  indicates  a  grave  and  prob- 
ably fatal  form  of  sepsis.  If  the  temperature  is  at  first  only  slightly  in- 
creased, but  gradually  rises  to  103°  or  10-1°  F.,  it  denotes  progressive  sepsis. 
A  high  temperature  and  a  firm  pulse,  not  exceeding  120  beats  to  the  minute, 
are  indications  of  less  serious  import  than  a  low  temperature  with  a  rapid, 
feeble  pulse.  The  eyes  are  sunken,  often  suffused  with  an  abundant  secre- 
tion from  the  conjunctiva.  The  features  present  a  stolid  appearance,  with- 
out any  expression  of  intelligence.  Capillary  oozing  at  the  primary  seat  of 
infection  is  a  common  occurrence,  and  capillary  hgemorrhage  underneath  the 
skin  and  visible  mucous  membranes  is  frequently  observed.  Vomiting  and 
diarrhoea  are  often  present  from  the  beginning,  and  in  rapidly-fatal  cases 
remain  as  persistent  symptoms,  in  spite  of  measures  that  may  be  employed  to 
subdue  them.  The  discharges  from  the  bowels  are  often  stained  with  blood. 
The  urine,  as  a  rule,  is  scanty  and  loaded  with  urates. 

Billroth  placed  great  importance  upon  the  appearance  of  the  tongue. 
The  tongue  is  always  coated;  in  grave  cases  it  is  pointed  at  the  tip,  its  mar- 
gins are  red,  while  the  dorsal  surface  is  dry  and  covered  with  a  dry,  often 
almost  black,  crust.  Eeturn  of  moisture  is  always  a  favorable  omen.  Great 
thirst  and  complete  loss  of  appetite  are  always  present.  Delirium  is  a  fre- 
quent, but  not  a  constant,  symptom.    If  the  case  progress  to  a  fatal  termina- 


CLINICAL    FOEMS    OF    SEPTICiEMIA.  379 

tion,  the  pulse  becomes  more  and  more  frequent,  respirations  become  shallow 
and  labored,  the  face  presents  a  cyanotic  hue,  the  surface  is  bathed  with  a 
clammy  perspiration,  the  extremities  become  cold,  and  death  finally  is  caused 
from  heart-failure.  In  the  differential  diagnosis  it  is  important  to  remem- 
ber fermentation  fever,  septic  intoxication,  typhoid  fever,  internal  sepsis,  and 
acute  multiple  suppurative  osteomyelitis.  Progressive  septicasmia  always  has 
a  stage  of  incubation;  that  is,  a  certain  length  of  time  intervenes  between 
the  time  infection  occurred  and  the  appearance  of  the  disease.  This  period 
of  incubation  may  terminate  at  the  end  of  a  few  hours  and  it  may  be  pro- 
longed to  four  days,  according  to  the  number  of  pus-microbes  introduced 
and  the  anatomical  structure  and  physiological  properties  of  the  tissues  pri- 
marily infected.  Fermentation  fever  follows  an  injury  or  operation  within 
a  few  hours,  and  never  occurs  after  the  expiration  of  twenty-four  hours.  In 
fermentation  fever  the  maximum  symptoms  appear  at  once,  and  the  force  of 
the  pulse  and  strength  of  the  patient  remain  unimpaired.  Fermentation 
fever  seldom  lasts  for  more  than  one  or  two  days,  while  in  progressive  sepsis 
the  symptoms  become  aggravated  as  the  infection  increases.  In  putrid  in- 
toxication the  maximum  symptoms  are  produced  by  the  introduction  into 
the  blood  of  preformed  soluble  toxic  substances  from  a  depot  of  putrefaction. 
Evidences  of  putrefaction  in  any  part  of  the  body  would  speak  in  favor  of 
septic  intoxication,  while,  if  septic  infection  exist  at  the  same  time,  it  must 
be  regarded  not  in  the  light  of  a  cause,  but  as  a  complication.  Typhoid  fever 
is  preceded  by  a  well-marked  prodromal  stage  which  is  absent  in  septic  in- 
fection. The  eruption  in  typhoid  fever  is  characteristic,  while  the  eruption 
which  is  sometimes  seen  in  progressive  sepsis  closely  resembles  the  rash  of 
scarlatina,  and  is  caused  by  the  presence  of  pus-microbes  in  the  superficial 
lymphatic  vessels.  Internal  sepsis  is  usually  preceded  by  a  septic  pharyn- 
gitis, and  frequently  attended  by  ulcerative  endocarditis.  Acute  multiple 
osteomyelitis,  the  cause  of  fatal  septic  infection,  can  be  recognized  by  search- 
ing for  points  of  tenderness  in  the  localities  attacked  most  frequently  by  this 
disease.  The  final  diagnosis  of  septic  infection  must  be  based  upon  the  ex- 
istence of  an  infection-atrium,  through  which  pus-microbes  have  entered  the 
tissues,  and  from  which  they  have  reached  the  general  circulation. 

Prognosis.— The  prognosis  of  progressive  septicaemia  is  always  grave. 
In  cases  where  pus-microbes  exist  in  large  numbers  at  the  primary  seat  of 
infection,  and  reach  the  general  circulation  with  great  rapidity,  and  meet 
with  conditions  favorable  for  their  reproduction,  death  is  inevitable  in  spite 
of  the  most  energetic  local  and  general  treatment.  The  prognosis  is  more 
favorable  if  infection  has  taken  place  from  a  locality  amenable  to  thorough 
local  disinfection,  if  this  is  practiced  upon  the  first  appearance  of  symptoms, 
as  this  treatment  prevents  further  ingress  of  pus-microbes  into  the  circula- 
tion.   The  existence  of  multiple  points  of  metastatic  inflammation  renders  a 


380  PRINCIPLES    OF    SURGERY. 

recovery  improbable.  Delirium,  rapid  and  feeble  pulse,  subnormal  tempera- 
ture, dry  tongue,  persistent  vomiting  and  diarrhoea  are  all  unfavorable  symp- 
toms from  a  prognostic  stand-point.  Capillary  haemorrhages  distant  from 
the  primary  infection-atrium  are  infallible  indications  of  progressive  sepsis, 
and  their  existence  warrants  a  most  unfavorable  prognosis.  Progressive  sep- 
sis may  cause  death  in  twelve  hours,  and  in  fatal  cases  life  is  seldom  pro- 
longed for  more  than  one  week. 

Pathology  and  Morbid  Anatomy. — In  rapidly-fatal  cases  of  progressive 
septic  infection,  the  absence  of  gross  macroscopical  pathological  changes  is  a 
characteristic  feature  of  this  disease.  In  such  instances  even  the  most  careful 
search  for  tangible  lesions  will  result  negatively.  Cloudy  swelling  of  the 
parenchyma  of  internal  organs  indicates  the  existence  of  coagulation-necro- 
sis, caused  by  the  action  of  the  toxins  of  the  pus-microbes.  Pus-microbes 
have  been  frequently  found  in  septic  blood.  Hsemorrhagic  extravasations 
into  organs,  and  more  particularly  underneath  serous  and  mucous  mem- 
branes and  the  skin,  are  frequently  present.  The  blood  presents  almost  a 
black  color,  and  shows  little  or  no  tendency  to  coagulate.  The  lymphatics 
interposed  between  the  primary  seat  of  infection  and  the  blood-vessels  are 
frequently  found  in  a  state  of  septic  inflammation.  The  wound  through 
which  infection  has  taken  place  may  present  but  slight  or  no  gross  anatom- 
ical changes.  .  The  spleen  is  enlarged  and  the  pulpa  softened  to  the  consist- 
ency of  a  blood-clot.  Thrombosis  and  embolism  are  absent.  Under  the 
microscope  the  capillary  vessels  everywhere  present  all  the  evidences  of  a 
septic  inflammation.  The  soluble  toxins  in  the  blood  produce  coagulation- 
necrosis  of  the  intima,  which  determines  mural  implantation  of  the  pus- 
microbes  and  the  colorless  corpuscles  and  results  in  capillary  hypersemia  and 
congestion.  In  some  places  alteration  of  the  capillary  wall  has  taken  place 
to  such  an  extent  as  to  give  rise  to  rhexis.  The  most  important  microscopical 
changes  in  the  tissues  and  organs,  in  patients  who  have  died  of  sepsis,  are  the 
pathological  conditions  within  and  in  the  immediate  vicinity  of  capillary 
vessels  that  indicate  the  existence  of  multiple  foci  of  metastatic  inflamma- 
tion, which  characterize  clinically  and  pathologically  progressive  sepsis.  If 
life  is  prolonged  for  a  sufficient  length  of  time,  these  foci  become  the  centre 
of  a  suppurative  inflammation.  Slight  effusions  into  the  large  serous  cavities 
are  frequently  found. 

Treatment. — The  antiseptic  measures  which  have  been  described  in  the 
treatment  of  wounds  are  the  best  and  only  known  means  of  effective  prophy- 
laxis against  septic  infection.  Any  method  or  methods  of  treatment  which 
can  be  relied  upon  in  the  prevention  of  suppuration  will  be  found  efficient 
in  preventing  septic  infection.  As  retention  of  wound-secretion  is  one  of  the 
important  etiological  conditions  in  the  causation  of  septic  infection  in 
wounds  that  are  not  completely  aseptic,  drainage  should  be  employed  in  all 


CLINICAL    FOKMS    OF    SEPTICEMIA.  381 

cases  where  an  accumulation  of  the  primary  wound-secretion  is  to  be  feared. 
As  septic  infection  is  just  as  liable  to  occur  through  a  small  as  a  large  wound, 
the  most  insignificant  injury  should  be  treated  upon  the  strictest  and  most 
pedantic  antiseptic  precautions.  If,  in  spite  of  the  greatest  care,  symptoms 
of  septic  infection  appear  after  an  injury  or  operation,  no  time  should  be 
lost  by  the  useless  administration  of  antipyretics,  in  the  vain  hope  that  by 
reducing  the  temperature  the  condition  of  the  patient  will  be  improved,  but 
the  first  and  essential  object  of  treatment  should  be  to  remove  the  cause  of  the 
fever  by  resorting  to  secondary  disinfection.  All  sutures  must  be  removed 
and  every  portion  of  the  wound  rendered  accessible  to  local  treatment.  Ex- 
travasated  blood  and  necrosed  shreds  of  tissue  must  be  removed,  when  the 
wound  is  to  be  irrigated  with  a  1-to-lOOO  solution  of  corrosive  sublimate  or 
a  5-per-cent.  solution  of  carbolic  acid,  after  which  it  is  dried  and  the  whole 
surface  brushed  with  a  10-per-cent.  solution  of  chloride  of  zinc.  After  an- 
other irrigation  and  after  drying  the  surface  again,  a  thin  film  of  iodoform  is 
applied,  and  then  the  wound  is  tamponed  with  iodoform  gauze,  over  which 
a  moist  antiseptic  compress  is  applied.  Such  a  wound  should  never  be  re- 
sutured  until  the  local  and  general  symptoms  indicate  that  it  has  been  ren- 
dered completly  aseptic.  If  this  secondary  disinfection  prove  unsuccessful, 
recourse  should  be  had  to  permanent  irrigation  with  a  saturated  solution  of 
acetate  of  aluminum.  Secondary  disinfection  of  the  peritoneal  cavity,  in 
cases  of  septic  peritonitis  after  laparotomy,  has  so  far  not  proved  very  satis- 
factory, but  as  it  is  the  only  recourse  in  dealing  with  such  desperate  cases, 
that,  without  it,  would  surely  run  a  fatal  course  in  a  short  time,  it  should 
never  be  neglected.  A  number  of  the  sutures  near  the  lower  angle  of  the 
wound  are  removed,  with  blunt  instruments  the  margins  of  the  wound  are 
separated,  and  the  abdominal  cavity  is  fiushed  with  warm  salicylated  water 
until  the  fiuid  returns  perfectly  clear.  The  end  of  the  rubber  tube  attached 
to  the  irrigator  must  be  inserted  in  such  a  manner  that  the  stream  will  reach 
the  most  dependent  portions  of  the  abdominal  cavity;  hence  it  is  inserted 
into  the  deepest  portion  of  the  pelvis,  and  when  this  portion  of  the  abdom- 
inal cavity  has  been  thoroughly  washed  out  the  lumbar  regions  are  dealt  with 
in  a  similar  manner.  After  the  irrigation  has  been  completed,  the  patient 
is  turned  upon  the  face,  so  as  to  permit  the  escape  of  fluid  by  gravitation. 
A  large  glass  drain  is  lightly  packed  with  a  strip  of  iodoform  gauze,  after 
which  the  antiseptic  dressing  is  applied  in  such  a  manner  that  the  end  of  the 
tube  remains  accessible  to  the  removal  of  fluid  by  aspiration  as  often  as  cir- 
cumstances may  require.  In  progressive  sepsis,  following  in  the  course  of 
progressive  gangrene  of  a  limb,  amputation  will  become  necessary  if  second- 
ary disinfection  and  permanent  irrigation  have  proved  of  no  avail  in  arrest- 
ing the  septic  infection.  The  general  treatment  of  septic  infection  is  the 
same  as  has  been  advised  in  cases  of  septic  intoxication. 


383  PEINCIPLES    OF    SUKGEKY. 

The  general  treatment  of  sepsis  consists  in  the  employment  of  stimu- 
lants, notably  alcohol  and  strychnia,  not  in  measured  doses,  but  in  quantities 
which  will  produce  the  desired  result. 

INTESTINAL    SEPSIS. 

The  subject  of  intestinal  sepsis,  in  connection  with  the  bacillus  coli 
communis,  has  received  a  good  deal  of  attention,  during  the  last  five  or  six 
years,  on  the  part  of  bacteriologists,  physicians,  and  surgeons.  Intestinal 
infection  may  be  limited  to  the  absorption  of  the  toxins  of  pathogenic  bac- 
teria, when  it  is  called  intestinal  toxemia,  •enterosepsis  (Billroth),  enteritis 
septica  (Gussenbauer),  or  it  may  be  of  a  more  dangerous  character  when  the 
bacteria  enter  the  general  circulation  from  the  intestinal  mucous  surface. 
Karlinski  fed  animals  with  milk  infected  with  staphylococcus  aureus. 
Among  forty-eight  experiments  he  found  six  times  general  infection  with 
swelling  and  redness  of  the  intestinal  mucosa,  while  the  iseces  and  the  blood 
both  showed  the  same  cocci.  Five  times  he  found  suppurative  parotitis  with- 
out intestinal  lesions;  seventeen  times,  acute  and  fatal  diarrhoea;  eight 
times,  general  infection  with  metastatic  abscess.  Aside  from  these  experi- 
ments^ there  are  numerous  other  observations,  all  tending  to  show  that  the 
most  common  microbe  of  the  intestinal  canal,  the  bacillus  coli  communis, 
may  enter  the  general  circulation  and,  becoming  localized  in  distant  parts, 
cause  suppuration.  In  this  way  are  to  be  explained  the  abscesses  in  the  liver 
which  accompany  or  follow  dysentery,  and  in  which  living  microbes  have 
been  described  by  Kartulis,  Osier,  and  others.  Constipation  is  not  an  essen- 
tial condition  in  the  production  of  intestinal  toxaemia  and  sepsis,  as,  in  some 
cases,  for  reasons  which  at  present  cannot  be  explained,  these  conditions  are 
associated  with  diarrhoea. 


CHAPTER  XV. 


Pyemia. 


Pyaemia,  or  pyohsemia,  is  a  general  disease  caused  by  the  entrance  into 
the  circulation  of  pus  or  some  of  its  component  parts,  characterized  by  re- 
curring chills,  an  intermittent  form  of  fever,  and  the  occurrence  of  meta- 
static abscesses.  Although  this  disease  was  known  a  long  time  before  Piorry 
applied  to  it  the  name  it  still  bears,  its  intimate  relationship  to  suppurative 
processes  was  first  pointed  out  by  this  surgeon.  Piorry  maintained  that,  as 
the  name  implies,  pygemia  is  caused  by  the  entrance  of  pus  into  the  blood. 
Virchow,  on  the  other  hand,  contended  that  no  pus  is  found  in  the  blood 
of  pysemic  pati-ents,  and  that  the  secondary  or  metastatic  abscesses  are  not 
true  abscesses  resulting  from  the  accumulation  of  pus  derived  from  the 
blood,  but  that  they  are  the  result  of  embolic  processes,  puriform  softening, 
inflammation,  and  suppuration  around  the  blocked  vessels.  Eecent  bacterio- 
logical investigations  have  shown  that  Piorry's  views  are  so  far  correct  in 
that  pus  is  produced  within  blood-vessels  by  the  entrance  of  pus-microbes 
into  the  circulation.  As  a  wound  complication  pygemia  can  only  occur  after 
suppuration  has  taken  place  in  a  wound,  and,  as  a  complication  of  non-trau- 
matic lesions,  it  can  only  develop  in  the  course  of  suppurative  affections. 
The  great  prevalence  of  pyaemia  in  overcrowded  and  badly-ventilated  hos- 
pitals, during  the  time  before  the  antiseptic  treatment  of  wounds  came  into 
use,  gave  rise  to  a  general  belief  that  the  disease  was  due  to  a  specific  cause, 
and  ever  since  bacteriology  became  a  science  diligent  search  has  been  made 
to  discover  the  specific  microbe.  Since  the  discovery  of  the  microbes  of  sup- 
puration, new  light  has  been  shed  upon  the  etiology  and  pathology  of  this 
disease.  Bacteriological  examinations  of  pysemic  products  have  shown  that 
one  or  more  kinds  of  pus-microbes  are  always  present,  thus  establishing  the 
direct  relationship  which  exists  between  a  suppurating  process  in  some  part 
of  the  body  and  the  development  of  metastatic  or  pysemic  abscesses.  Clinical 
experience  has  only  corroborated  the  scientific  investigations  of  this  subject, 
inasmuch  as  it  has  shown  that  the  frequency  of  pygemia  has  been  diminished 
in  proportion  to  the  lesser  frequency  of  suppurative  inflammation  under  the 
antiseptic  treatment  of  wounds  and  suppurating  lesions.  We  are  Justified, 
upon  the  basis  of  well-established  facts,  in  claiming  that  pyaemia  is  not  a 
disease  per  se,  but  that  its  occurrence  depends  upon  an  extension  of  a  sup- 
purative process  from  the  primary  seat  of  infection,  and  suppuration  in  dis- 
tant organs  by  the  transportation  of  emboli  infected  with  pus-microbes 
through  the  systemic  circulation.    The  distant,  or  metastatic,  abscesses  con- 

(383) 


384  PEINCIPLES    OF    SUKGEEY. 

tain  the  same  microbes  wliicli  are  found  in  the  wound-secretions,  or  in  the 
abscess  from  which  the  general  purulent  infection  took  place.  Experiments 
have  shown  that  a  culture  of  pus-microbes  from  a  furuncle  may  produce 
pysemia  in  animals,  and  that  the  microbes  cultivated  from  a  pysemic  abscess, 
when  injected  under  the  skin  of  an  animal,  may  cause  only  a  localized  sup- 
purative inflammation  without  any  general  symptoms. 

BACTERIOLOGICAL  AND  EXPERIMENTAL  RESEARCHES. 

While  the  direct  relationship  existing  between  suppuration  and  pyaemia 
was  well  understood  clinically  for  a  long  time,  it  was  left  for  Klebs  to  dem- 
onstrate for  the  first  time  the  direct  connection  of  the  pygemic  processes  with 
the  presence  of  specific  microbes.  In  his  researches  into  the  nature  of  this 
disease  during  the  Franco-Prussian  war  in  1870,  he  discovered  in  the  pygemic 
products  certain  microorganisms  which  he  called  micrococci  of  pyaemia.  He 
found  that  these  microbes  always  arranged  themselves  in  the  form  of  colonies 
or  groups  which  he  termed  zobgloea.  He  found  this  microbe  invariably  pres- 
ent, notably  at  the  primary  seat  of  infection,  but  also  in  the  most  distant 
organs, — wherever,  indeed,  pathological  changes  occurred  during  the  course 
of  the  disease.  Pasteur,  in  studying  the  puerperal  form  of  pyaemia,  discov- 
ered a  chain  coccus  which  undoubtedly  was  identical  with  the  streptococcus 
pyogenes,  but  which  he  called  microbe  en  chapelet.  Hueter  and  Yogt  found  a 
microorganism  in  pygemic  products  which  they  included  among  the  monads. 
Burdon-Sanderson  supposed  that  he  had  discovered  the  essential  microbic 
cause  of  pysemia  in  the  shape  of  a  "dumh-dell-shaped  germ,"  which  in  all  prob- 
ability was  a  staphylococcus. 

Schuller  examined  the  contents  of  metastatic  joint  affections  in  12  cases 
of  puerperal  pyaemia,  and  invariably  found  pus-microbes.  Eosenbach  in- 
vestigated 6  cases  of  typical  pyaemia  with  a  view  to  determine  the  nature  of 
the  microbes  present  in  the  pyaemic  products.  He  found  the  streptococcus 
pyogenes  present  in  the  blood,  and  metastatic  deposits  in  5  of  them;  in  2  of 
these  cases  staphylococci  were  also  present,  although  fewer  in  number.  In 
only  1  of  them  he  found  staphylococci  alone,  and  this  case  recovered.  Paw- 
lowsky  made  a  bacteriological  examination  of  the  pus  of  metastatic  abscesses 
in  5  cases  of  pyaemia.  In  4  cases  he  found  the  staphylococcus  pyogenes 
aureus,  and  in  the  fifth  case,  which  was  remarkable  for  the  extent  of  the 
joint  complications,  he  found  the  streptococcus  pyogenes.  He  believes  that 
the  staphylococcus  pyogenes  aureus  is  the  usual  cause  of  pyaemia,  and  espe- 
cially of  that  form  characterized  by  multiple  abscesses  in  the  internal  organs. 
Large  cultures  of  this  coccus  suspended  in  water  and  injected  subcutaneously 
in  rabbits  caused  death,  and  at  the  necropsy  multiple  abscesses  were  found. 
He  maintains  that  pyaemia  in  man  occurs  when  disturbances  in  the  circula- 
tion are  present,  so  that  floating  cocci  find  favorable  points  for  localization 


BACTEKIOLOGICAL    A^^D    EXPEKIMENTAL    EESEAECHES.  385 

within  the  blood-vessels.  He  created  such  disturbances  artificially  in  ani- 
mals by  making  intravenous  injections  of  cinnabar,  with  the  result  that  the 
granular  material  determined  localization  of  the  microbes  which  were  intro- 
duced into  the  circulation. 

Besser  examined  bacteriologically  blood,  pus,  and  parenchymatous  fluid 
from  organs  in  23  cases  of  pyaemia.  In  8  cases  the  staphylococci  albi  and 
aurei  were  found;  in  14,  streptococci;  and  in  1,  streptococci  and  staphylo- 
cocci simultaneously.  The  microbes  were  discovered  during  the  patient^s 
life  in  pus  in  every  one  of  20  cases  examined;  in  blood,  in  11  of  12;  and  in 
parenchymatous  serum,  in  1.  After  death,  in  pus,  in  17  of  17;  in  blood,  4 
of  9;  and  in  organs,  9  of  14.  Besser^s  predecessors  described  23  additional 
cases  of  pygemia.,  in  14  of  which  staphylococci  were  found;  in  7,  streptococci. 
Total,  46  eases:  in  22,  staphylococci;  in  21,  streptococci;  in  3,  both.  Besser 
was  unable  to  detect  the  slightest  morphological  or  pathogenic  difference 
between  the  microbes  of  suppuration  and  those  of  pyaemia. 

Okinschitz  made  the  relationship  which  exists  between  the  pus-microbes 
and  pygemia  the  subject  of  bacteriological  investigation.  He  found  that 
pysemic  blood  invariably  contained  either  the  streptococcus  pyogenes  or  the 
staphylococcus  pyogenes  aureus,  demonstrated  by  cultivation  and  ordinary 
microscopical  examination.  As  the  hgemic  microbes  seldom  show  any  signs 
of  fission,  as  compared  with  the  bacteria  at  the  primary  focus,  it  is  reason- 
able to  infer  that  reproduction  takes  place  mainly  in  the  pus,  and  not  in  the 
blood;  hence  the  great  importance  of  thorough  disinfection  and  destruction 
of  primary  foci.  The  number  of  microbes  in  the  circulating  blood  bears  a 
direct  relation  to  the  gravity  of  the  disease.  If  they  are  abundant,  even  in 
the  absence  of  metastases  in  internal  organs,  the  prognosis  is  grave,  and  if 
scanty,  even  if  metastatic  foci  are  present,  the  prospects  of  a  favorable  ter- 
mination are  better. 

Masius  and  Beco  record  two  cases  of  pyemia  due  to  the  staphylococcus, 
in  both  of  which  they  discovered  the  microorganisms  in  the  blood.  Kose 
injected  animals  with  virulent  cultures  of  the  staphylococcus  after  injection 
of  attenuated  cultures.  The  animals  survived.  The  blood  caused  a  marked 
agglutination  of  staphylococci,  and  these  organisms  would  not  grow  on  thin 
blood-serum.  He  believes  that  this  behavior  of  microbes  is  a  matter  of  great 
importance,  as  it  may  indicate  that  we  have  in  Widal's  method  a  means  of 
making  an  accurate  diagnosis  of  the  nature  of  infections  in  endocarditis  and 
septicsemia.  He  also  suggests  that  an  antistaphylococcic  serum  may  prove 
more  efficient  as  a  therapeutic  agent  than  the  antistreptococcic  serum,  since 
staphylococci  are  not  so  variable  in  virulence  as  the  streptococci. 

Pysemia  in  Rabbits. — Koch  produced  pygemia  artificially  in  rabbits  by 
injecting  putrid  fiuids.  A  piece  of  a  mouse's  skin,  about  a  square  centimetre 
in  size,  was  macerated  for  two  days  in  30  grammes  of  distilled  water,  and  a 


386 


PEINCIPLES    OF    SURGEKY. 


syringeful  of  this  fluid  was  injected  subcutaneously  into  the  back  of  a  rabbit. 
Two  days  the  animal  remained  apparently  well,  then  it  began  to  eat  less, 
became  gradually  weaker,  and  died  one  hundred  and  five  hours  after  the  in- 
jection. An  extensive  subcutaneous  abscess  was  found  at  the  seat  of  injec- 
tion. In  the  abdominal  wall  the  yellowish  infiltration  extended  in  part 
through  the  muscles  and  even  to  the  peritoneum.  The  peritoneal  surface 
presented  evidences  of  inflammation.  The  intestines  were  adherent,  and  the 
peritoneal  cavity  contained  a  small  quantity  of  turbid  fluid.  The  liver 
showed,  on  section,  gray,  wedge-shaped  patches.    In  the  lungs  infarcts  the 


A— . 


Fig.  143. — Vessel  from  the  Cortex  of  the  Kidney  of  a  Pyasmic  Rabbit.  A,  nuclei 
of  the  vascular  wall;  B,  small  group  of  micrococci  between  blood-corpuscles;  C,  dense 
masses  of  micrococci  adherent  to  the  wall  and  inclosing  blood-corpuscles;  D,  pairs  of 
micrococci  at  the  border  of  the  large  mass.     X  700.     {Koch.)''- 


size  of  a  pea  were  found.  A  syringeful  of  blood  taken  from  the  heart  of  this 
animal  was  now  injected  under  the  skin  of  the  back  of  a  second  rabbit.  The 
second  animal  died  in  forty  hours,  and  at  the  necropsy  nearly  the  same 
pathological  conditions  were  found,  only  that  the  peritonitis  was  less  ad- 
vanced. Further  experiments  showed  that  Vio  drop  of  pyasmic  blood  proved 
fatal  in  rabbits  in  one  hundred  and  twenty-flve  hours.    All  subsequent  ex- 


1  Copied   from   "Traumatic   Infective    Diseases," 
Society,  London. 


by   permission   of   the   New    Sydenham 


BACTERIOLOGICAL    AIS^D    EXPERIMENTAL    RESEARCHES.  387 

periments  proved  tliat^  the  less  the  quantity  of  blood  injected,  the  longer  the 
time  which  elapsed  before  death  occurred;  bnt  where  the  quantity  was  re- 
duced to  the  one-thousandth  part  of  a  drop,  no  result  followed.  On  micro- 
scopical examination  cocci  were  found  ^in  great  numbers  everywhere  through- 
out the  body,  and  more  especially  in  the  parts  which  had  undergone  altera- 
tions visible  to  the  naked  eye. 

The  description  of  the  microbe  found  corresponds  with  the  staphylo- 
coccus. The  relation  of  the  microbes  to  the  blood-vessels  could  be  seen  best 
in  the  renal  capillaries  (Fig.  143).  In  the  interior  of  the  vessel,  at  C,  is  a 
dense  deposit  of  micrococci  adherent  to  the  wall,  and  inclosing  in  its  sub- 
stance a  number  of  red  blood-corpuscles.  The  capillary  stasis  is  either  due 
to  the  power  of  the  microbes  of  causing  the  red  blood-corpuscles,  to  which 
they  adhere,  to  stick  together,  or  their  property  of  producing  in  their  imme- 
diate vicinity  coagulation  of  the  blood,  and  thus  cause  thrombosis.  The  mi- 
crobes were  found  so  arranged  that  they  inclosed  red  blood-corpuscles  in  the 
capillary  vessels  of  all  the  organs  examined,  as,  for  example,  in  the  spleen 
and  in  the  lungs.  Koch  believes  that  the  large  metastatic  deposits  in  the 
liver  and  in  the  lungs  do  not  arise  by  gradual  growth  of  a  mass  of  micro- 
cocci, as  in  Fig.  143,  but  by  the  arrest  of  large  groups  and  of  the  clots  asso- 
ciated with  them;  in  other  words,  by  true  embolism.  In  the  metastatic  de- 
posits an  extensive  development  of  micrococci  occurs,  and  these  are  not  con- 
fined to  the  vessels,  but  invade  the  neighboring  tissues.  In  the  peritoneal 
cavity  the  micrococci  were  not  found  in  large  masses,  but  isolated,  in  pairs  or 
in  small  groups. 

In  the  vicinity  of  the  abscess  he  detected  the  microbes  in  the  walls  of 
veins,  and  their  passage  through  these  into  the  interior  of  the  vessels  could 
be  readily  discerned  in  many  places.  As  Koch  has  pointed  out,  the  microbe 
of  pygemia  in  rabbits,  which  is  a  pus-microbe,  when  brought  in  contact  with 
the  red  blood-corpuscles,  increases  their  viscosity  and  they  form  larger  or 
small  coagula  in  the  blood.  They  can  thus  no  longer  pass  through  the 
minute  capillary  net-work,  but  are  arrested  in  the  smaller  vessels.  From  the 
point  of  infection  fresh  micrococci  pass  constantly  into  the  blood,  and  also 
individual  micrococci  will  become  detached  from  these  small  thrombi  and 
emboli,  and  mix  with  the  blood-stream.  As  the  microbes  are  constantly  be- 
ing deposited  by  mural  implantation,  their  number  in  the  circulating  blood 
always  remains  relatively  small.  Klein  described  a  micrococcus  of  pyemia 
in  mice.  Certain  cocci  which  were  present  in  pork  proved  fatal  to  mice  in 
about  a  week,  producing  both  purulent  inflammation  at  the  point  of  injec- 
tion and  metastatic  abscesses  in  the  lungs.  Inoculations  in  the  same  species 
of  animal  with  pyasmic  products  reproduced  the  disease  in  a  typical  manner. 
Pawlowsky  found  that  by  simultaneous  injection  of  sterilized  cinnabar,  and 
of  cultures  of  staphylococcus  pyogenes  aureus  into  the  circulation,  he  pro- 


388  PEINOIPLES    OF    SUEGEEY. 

duced  abscesses  in  various  organs;  in  fact,  the  typical  picture  of  p3'a3mia. 
The  presence  of  particles  of  foreign  bodies  rendered  material  aid  in  the  de- 
velopment of  metastatic  abscesses,  as  the  mere  arrest  of  pus-microbes  in  the 
circulation  without  them,  as  a  rule,  was  not  found  sufficient  of  itself  to  lead 
to  the  production  of  true  pysemia.  In  rabbits,  even,  the  introduction  of  a 
large  quantity  of  a  culture  of  pus-microbes  into  the  circulation  did  not  pro- 
duce pyaemia.  Twenty-four  hours  after  the  injection  he  found  the  microbes 
in  large  numbers  in  the  pulmonary  and  other  capillaries,  but  after  forty- 
eight  hours  they  had  all  disappeared  from  the  blood.  If  the  cocci  are  in- 
corporated in,  or  are  attached  to,  an  embolus,  this  latter,  by  producing  altera- 
tions in  the  endothelia  of  the  blood-vessels  at  the  point  of  impaction,  creates 
a  locus  minoris  resistentice  favorable  to  the  growth  of  the  microbes.  In  the 
experiments  of  Pawlowsky,  the  particles  of  cinnabar  acted  upon  the  endo- 
thelial lining  of  the  capillary  vessels  in  the  same  manner  as  the  fragments  of 
a  thrombus,  by  impairing  the  local  nutrition  of  the  tissues  with  which  they 
were  brought  into  contact. 

ETIOLOGY. 

If  pygemia  can  be  artificially  produced  in  rabbits,  mice,  and  guinea-pigs 
with  pus  or  with  a  pure  cultivation  of  the  same  with  or  without  the  presence 
of  foreign  bodies,  the  same  local  conditions  are  first  produced  at  the  point 
of  inoculation  which  invariably  precede  the  development  of  pyaemia  in  man. 
Some  of  the  veins  at  the  seat  of  primary  infection  are  invaded  by  pus-mi- 
crobes, and  become  blocked  by  a  thrombus;  this  thrombus  undergoes  puri- 
form  softening;  small  fragments  containing  pus-microbes  become  detached 
and  are  washed  away  and  enter  the  general  circulation  as  emboli,  which, 
when  they  become  arrested,  establish  independent  centres  of  suppuration. 
In  such  cases  the  same  microbes  can  be  found  in  the  wound,  in  the  blood, 
in  the  tissues  around  the  abscess,  and  in  all  distant  pyasmic  products.  Al- 
though the  streptococcus  pyogenes  has  been  found  most  frequently  in  the 
pus  at  the  primary  seat  of  infection  and  in  the  metastatic  abscesses  of  py- 
semic  patients,  there  can  be  but  little  doubt  that  any  of  the  pus-microbes, 
when  present  in  sufficient  quantity  in  the  blood,  can  produce  the  disease. 
The  occurrence  of  pycemia  from  suppurating  loounds  or  abscesses  does  not 
depend  so  much  upon  the  hind  of  pus-microhes  which  have  caused  the  primary 
suppuration  as  upon  surrounding  circumstances.  The  location  and  ana- 
tomical structure  of  the  tissues  in  which  the  primary  infection  has  tahen  place 
exert  an  important  influence  in  the  production  of  the  disease. 

It  is  an  exceedingly  familiar  clinical  fact  that  suppurative  inflammation 
of  the  medullary  tissue  in  bone  is  frequently  the  cause  of  pysemia.  Acute 
suppurative  osteomyelitis  without  direct  infection  through  a  wound  is  always 
due  to  intravascular  infection:   localization  of  pus-microbes  in  the  capillary 


ETIOLOGY. 


389 


vessels  of  the  medullary  tissue.  The  microbes  come  first  in  contact  with  the 
endothelial-cells  when  mural  implantation  has  taken  place,  and  the  coagula- 
tion-necrosis which  follows  leads  to  thrombosis.  The  products  of  the  intra- 
vascular coagulation-necrosis  furnish  a  most  favorable  nutrient  substance  for 
the  growth  and  multiplication  of  the  pus-microbes;  consequently  the  area 
of  intravascular  infection  is  rapidly  increased.  The  growth  of  the  throm- 
bus in  a  proximal  direction  soon  leads  to  extensive  thrombophlebitis,  and, 
as  softening  of  the  thrombus  takes  place,  to  embolism  and  metastatic  sup- 
puration. Pygemia  following  a  suppurative  inflammation  in  a  wound,  or  in 
the  course  of  a  phlegmonous  inflammation  of  the  connective  tissue,  is  the 
result  of  an  infection  with  pus-microbes  which  penetrate  the  veins  from 
without.  The  pus-microbes,  coming  first  in  contact  with  the  outer  coats  of 
the  veins,  give  rise  .to  phlebitis,  which  progresses  from  without  inward,  and 
which  is  followed  by  thrombosis  as  soon  as  the  intima  is  reached.    The  intra- 


Fig.  144.— Suppurating  Thrombus  in  Vein.     (Tillmanns.) 

vascular  dissemination  of  the  pus-microbes  then  takes  place  in  the  same 
manner  as  in  cases  of  primary  thrombophlebitis.  Ordinary  pyogenic  microbes 
may  and  do  cause  pyaemia,  if  they  enter  the  blood  incorporated  in,  or  attached 
to,  fragments  of  an  infected  blood-dot,  or  other  solid  materials,  which,  after 
they  have  become  impacted  in  blood-vessels  as  emboli,  prepare  the  soil  in  distant 
organs  for  their  localization  and  reproduction. 

The  importance  of  thrombosis  and  embolism  as  essential  factors  in  the 
causation  of  pysemia  has  been  clearly  established  by  clinical  observation  and 
experimental  research.  Emboli  may  originate  in  the  lymphatic  vessels  when 
these  are  the  seat  of  invasion  by  pyogenic  microbes,  which,  however,  is  very 
seldom  the  case.  In  chronic  pysemia,  in  which  multiple  metastatic  abscesses 
are  formed,  embolism  takes  no  essential  part  in  the  process;  the  microbes 
enter  the  blood-current  without  such  a  vehicle,  and  are  brought  in  direct 
contact  by  mural  implantation  with  the  interior  lining  of  vessels  weakened 
by  injury  or  other  local  and  general  debilitating  influences.     Experimental 


390  PRINCIPLES    OF    SUEGEEY. 

research,  has  shown  conclusively  that  the  mere  introduction  of  pus-microbes 
into  the  circulation  is  not  necessarily,  or  even  usually,  followed  by  pyemia, 
and  their  accidental  entrance  in  the  course  of  a  suppurative  inflammation  is 
not  always  followed  by  serious  consequences.  Ther&  can  he  no  doubt  that 
some  pus-microhes  reach  the  circulation  in  nearly  every  case  of  suppuration, 
hut  their  pathogejiic  action  is  prevented,  or  neutralized,  by  an  adequate  resist- 
ance on  the  part  of  the  tissues  with  which  they  are  brought  in  contact  and 
their  rapid  elimination  through  healthy  excretory  organs.  A  limited  number 
of  pus-microbes  injected  into  the  circulation  of  a  healthy  animal,  or  acci- 
dentally introduced  into  the  blood  of  an  otherwise  healthy  person,  are  effect- 
ively disposed  of  by  the  white  blood-corpuscles.  If,  however,  the  same  num- 
ber of  microbes  are  present  in  combination  with  fragments  of  a  blood-clot, 
the  infected  foreign  particles  produce  such  nutritive  changes  in  the  tissues 
surrounding  them  as  to  transform  them  into  a  favorable  soil  for  the  pathog- 
enic action  of  the  microbes.  The  same  happens  if  free  pus-microbes  localize 
in  a  part  the  vitality  of  which  has  been  previously  diminished  by  trauma  or 
antecedent  pathological  changes,  which  constitutes  a  locus  minoris  resist&niicE 
for  the  growth  and  multiplication  of  the  pus-microbes.  Pygemia,  therefore, 
must  be  looked  upon  rather  as  a  serious  and  fatal  complication  of  suppura- 
tive lesions  than  an  independent  specific  disease.  The  immediate  causes  of 
pyaemia  are  the  formation  of  an  infected  thrombus  at  the  primary  seat  of 
infection,  and  disintegration  of  this  thrombus  to  such  an  extent  that  frag- 
ments become  detached  and  are  conveyed  by  the  blood-current  to  distant 
organs,  where  they  are  arrested  in  the  smaller  arteries  as  emboli. 

Thrombosis. — A  thrombus  is  an  intravascular  blood-clot  locally  formed 
within  the  heart  or  a  blood-vessel,  and  the  process  by  which  it  is  formed  is 
called  "thrombosis."  A  thrombus  is  called  venous  if  it  occur  in  a  vein,  arte- 
rial if  it  form  in  an  artery.  A  red  thrombus  is  produced  if  the  blood  coagu- 
late in  its  entirety,  while  a  white  thrombus  is  composed  of  fibrin  exclusively 
or  the  fibrin  and  the  colorless  and  third  corpuscles  of  the  blood.  A  mural 
thrombus  is  a  thrombus  which  is  attached  to  the  inner  surface  of  a  vessel- 
wall  without  occluding  the  entire  lumen  of  the  vessel.  Notwithstanding  the 
numerous  and  ingenious  experiments  which  have  been  made  for  the  purpose 
of  ascertaining  the  immediate  cause  of  intravascular  coagulation  of  the 
blood,  this  subject  awaits  a  more  satisfactory  explanation  than  can  be  given 
at  the  present  time.  Richardson,  Bruecke,  and  Lister  have  shown  that  the 
mere  mechanical  interruption  to  the  flow  of  blood  in  a  vessel  is  not  a  suffi- 
cient cause  of  coagulation.  Blood  has  been  kept  in  a  fluid  condition  in  a 
blood-vessel  between  two  ligatures  for  an  indefinite  period  of  time  in  the 
living  tissues. 

Virchow,  Cohnheim,  Baumgarten,  and  Zahn  maintain  that  the  colorless 
corpuscles  are  in  the  closest  manner  related  to  thrombus-formation.     Zahn, 


ETIOLOGY.  391 

from  observations  on  the  living  mesentery  of  the  frog,  found  that  when  the 
wall  of  a  vessel  was  injured  the  colorless  corpuscles  accumulate  around  the 
injured  part,  constituting  what  he  calls  a  white  thrombus.  The  corpuscles 
subsequently,  in  great  part,  disintegrate  and  give  rise  to  a  granular  accu- 
mulation,* which,  by  its  action  upon  the  fibrinogen  of  the  blood,  causes  a 
precipitation  of  fibrin. 

Since  the  discovery  of  the  third  corpuscle,  or  hcBmatoUast,  by  Hay  em 
and  Bizzozero,  the  part  taken  by  this  element  of  the  blood  in  the  process  of 
coagulation  has  been  carefully  studied  by  Eberth  and  Schimmelbusch.  The 
third  corpuscle  possesses  a  peculiar  property  to  adhere  to  any  foreign  body  or 
irregularity  of  surface  of  the  intima  of  the  blood-vessels.  The  authors  just 
quoted  found  that  when  a  vessel  is  injured,  as  by  tying  a  ligature  around  it 
and  removing  this  in  a  quarter  of  an  hour  afterward,  these  minute  blood- 
disks  manifest  a  peculiar  tendency  to  adhere  to  the  injured  part  of  the  tunica 
intima  and  to  each  other,  forming  a  white  mural  thrombus.  The  process  by 
which  mural  implantation  of  the  third  corpuscle  takes  place  these  authors 
call  conglutination,  the  mass  thus  formed  being  composed  primarily  and  ex- 
clusively of  this  morphological  element  of  the  blood.  If  an  aseptic  thread  is 
drawn  across  the  lumen  of  a  vessel  in  which  the  blood-current  is  moving, 
the  third  corpuscle  is  arrested  in  its  course  and  becomes  deposited  upon  the 
thread,  which,  in  time,  becomes  the  centre  of  a  white  thrombus.  Conglu- 
tination, under  such  circumstances,  is  a  purely  mechanical  process. 

Eberth  and  Schimmelbusch  demonstrated  by  their  experiments  that 
conglutination  is  most  liable  to  occur  where  irregularities  of  the  tunica 
intima  are  present.  If  by  a  trauma,  inflammatory  or  degenerative  changes 
take  place,  the  endothelial  lining  of  a  blood-vessel  is  rendered  rough  and  un- 
even; conglutination  takes  place  first  at  the  points  which  project  farthest 
into  the  lumen  of  the  vessel,  because  here  the  projecting  body  encroaches 
upon  the  axial  current,  which  conveys  the  third  corpuscle.  In  thrombosis 
through  pathological  causes,  mural  implantation  of  the  third  corpuscle  takes 
place  upon  an  intima  roughened  by  inflammatory  or  degenerative  changes. 
Arnold  has  very  recently  shown  that  the  red  corpuscles  take  an  important 
part  in  the  coagulation  of  blood  botli  inside  and  outside  of  the  body.  His 
studies  of  the  morphology  of  disintegration-product  of  red  blood-corpuscles, 
both  outside  of  the  body  as  well  as  within  the  vessels  of  the  mesentery  and 
omentum  of  living  animals,  establish  the  very  probable  identity  with  blood- 
platelets  of  some  of  the  bodies  which  separate  from  the  red  corpuscles  by 
processes  which  are  designated  as  plasmoschisis,  or  erythrocytoschisis,  and 
plasmorrhexis,  or  erythrocytorrhexis.  In  addition,  substances  in  solution' 
may  escape  from  the  red  corpuscles,  which  are  then  changed  into  "shadows" 
and  other  forms,  or  disappear  entirely.  This  is  called  plasmolysis.  In  both 
of  these  changes — the  extrusion  of  solid  particles  and  plasmolysis — fibrin, 


393  PEINCIPLES    OF    SUEGEEY. 

different  structurally  as  well  as  tinctorially,  is  formed,  smooth  threads, 
threads  partly  or  wholly  granular,  threads  containing  platelets,  and  frag- 
ments of  red  corpuscles,  showing  that  a  very  close  relation  exists  between 
fibrin-formation  and  the  red  corpuscles. 

The  investigations  of  Arnold  furnish  strong  evidence  in  favor  of  regard- 
ing the  formation  of  platelets  as  the  first  morphological  phase  of  coagulation, 
not  only  in  circulating  blood,  as  suggested  by  Welch,  but  also  in  extravas- 
cular  coagulation.  The  production  by  the  red  corpuscles  of  soluble  fibrinoid 
substances  may  induce  the  deposition  of  fibrin  around  leucocytes  and  endo- 
thelial cells  in  such  a  manner  as  to  reproduce  the  craters  of  coagulation 
described  by  Zenker  and  Hauser,  in  which  the  cells  mentioned  form  the  cen- 


Fig.  145.— White  Thrombus,     a,  slightly  granular  and  hyaline  masses  produced  by  the 
third  corpuscle;    6,  white  corpuscles;    d,  young  blood-vessel.     (Landerer.) 

tres,  radially  fibrinous  threads.  Thrombus- formation,  as  we  observe  it  in 
pycemia,  always  takes  place  upon  a  vessel-wall  altered  by  action  of  pus-mi- 
crobes. The  form  of  thrombosis  intimately  associated  with  the  etiology  and 
pathological  anatomy  of  pyaemia  occurs  in  a  vein  within  or  in  close  proxi- 
mity to  the  primary  suppurative  lesion.  The  close  relationship  of  phlebitis 
to  pysemia  was  well  understood  by  John  Hunter,  who  believed  that  the  for- 
mer always  preceded  the  latter.  He  taught  that  the  phlebitis  resulted  in 
intravenous  production  of  pus  and  the  formation  of  metastatic  abscesses. 
Cruveilhier,  on  the  other  hand,  regarded  thrombosis  as  the  first  link  in  the 
chain  of  pathological  conditions  in  pysemia.  The  idea  of  a  primary  throm- 
bosis as  a  cause  of  disease  was  carried  by  his  pupils  so  far  that  nearly  all  in- 
flammatory processes  were  by  them  attributed  to  thrombotic  changes  in 


ETIOLOGY. 


393 


small  veins;  not  only  inflammatory  lesions,  but  even  tnmors  were  supposed 
to  originate  in  this  manner.  A  new  aspect  was  given  to  the  pathology  of 
this  disease  by  the  careful  experimental  investigations  of  Yirchow  on  throm- 
bosis and  embolism.  He  showed  that  the  metastatic  deposits  always  occurred 
at  points  where  vessels  had  been  blocked  by  an  embolus  derived  from  a  dis- 
integrating thrombus.  In  the  light  of  recent  research  phlebitis  precedes' 
thrombus-formation  at  the  primary  seat  of  the  infection.  The  pus-microbes 
which  are  present  in  the  infected  tissues  permeate  the  vein-wall  and  induce 


Fig.  146.— Red  Thrombus.  Mosaic  of  Red  Corpuscles  Traversed  by  Young  Con- 
nective Tissue  from  tlie  Intima  Vessel-wall,  Infiltrated  by  a  Few  White  Corpuscles. 
{Landerer.) 

inflammatory  changes  characteristic  of  this  form  of  infection.  As  soon  as 
the  infection  has  reached  the  intima  this  structure  is  roughened,  and  upon 
the  projecting  points  conglutination  takes  place,  and  the  foundation  for  a 
thrombus  is  laid  by  a  pavement  composed  of  the  third  corpuscles  of  the  blood. 
Upon  this  surface  aggregation  of  the  colorless  corpuscles  takes  place,  and,  as 
these  structures  undergo  coagulation-necrosis,  fibrin  is  formed  and  a  red 
thrombus  is  established. 

The  pus-microbes,  which  have  reached  the  interior  of  the  vein  through 
the  inflamed  vein-wall,  multiply  in  the  thrombus,  and  produce  here,  as  else- 


394 


PEINCIPLES    OF    SUEGEET. 


where  under  similar  favorable  circumstances,  their  specific  pathogenic  ef!ect. 
The  thrombus  thus  formed  is  an  infected  thrombus,  which  condition  pre- 
cludes the  possibility  of  its  removal  by  absorption.  With  an  increase  of  the 
intravenous  infection  coagulation  is  hastened,  and  a  red  thrombus  soon  fills 
the  entire  lumen  of  the  vein,  surrounded  by  a  zone  composed  exclusively  of 
blood-disks,  colorless  corpuscles,  and  fibrin,  which  compose  its  mural  por- 
tion. As  soon  as  the  lumen  of  the  vein  has  been  completely  obstructed  the 
conditions  for  coagulation  are  improved,  and  the  thrombus  increases  in  size 
in  both  directions.  The  contact  of  the  blood  with  the  dead,  infected  throm- 
bus results  in  coagulation,  and  in  this  manner  layer  after  layer  is  added  to  the 


E'ig.  147. — Laminated  Thrombus  in  a  Vein.  The  dark,  granular  layers  are  com- 
posed of  colorless  blood-corpuscles  and  fibrin;  the  central,  lighter  portion,  of  red  corpus- 
cles.   1:97.     (Birch-Hirschfeld.) 

thrombus.  If  thrombus-formation  take  place  in  advance  of  the  primary 
phlebitis,  inflammation  of  the  vein-wall  follows  as  an  inevitable  consequence 
from  the  presence  of  the  infected  thrombus,  the  inflammatory  process  spread- 
ing, like  the  infection,  from  within  outward.  The  growth  of  a  thrombus  is 
seldom  arrested  in  a  central  direction  until  some  large  vein-trunk  is  reached, 
into  which  the  apex  of  the  thrombus  projects. 

The  blood-current  in  a  vein  into  which  the  apex  of  a  thrombus  from  an 
adjacent  vein  projects  frequently  arrests  its  proximal  extension,  but  if  the 
venous  circulation  is  impeded,  or  the  thrombus  continues  to  grow  by  the 
addition  of  new  layers,  in  spite  of  the  obstacles  presented,  one  portion  after 
another  of  a  vein  becomes  involved,  and  the  thrombus  rapidly  increases  in 


ETIOLOGY. 


395 


length  in  a  proximal  direction.  A  venous  thrombus  in  a  pygemic  patient  is 
only  loosely  attached  to  the  vein-wall,  as  the  pus-microhes  transform  the 
white  corpuscles,  which  remain  after  coagulation  has  occurred,  into  pus-cor- 
puscles, and  in  this  manner  softening  and  disintegration  of  the  thrombus  are 
accomplished.  If  a  thrombus,  at  the  point  where  it  is  in  contact  with  the 
venous  circulation  on  the  proximal  side,  become  sufficiently  softened,  frag- 
ments become  detached  and  are  carried  away  by  the  venous  current  as 
emboli. 

Embolism. — A71  embolus  is  a  detaclied  tlirotnbus,  part  of  a  thrombus,  or 
any  foreign  substance  transported  by  the  arterial  bhod-current  to  its  place  of 
impaction.  The  process  or  act  by  which  this  is  accomplished  is  called  embolism. 
The  obstructed  artery  and  the  tissues  affected  by  the  interrupted  circulation 


Fig.  148.— Thrombophlebitis.     A,  central  end.  of  venous  thrombus  projecting  into  a 
larger  vein-trunk;    B,  vein-branch  not  closed  by  a  thrombus.     {Billroth.) 


constitute  what  is  known  as  an  infarct.  The  histology  of  an  infarct  as  it 
presents  itself  in  the  kidney  has  been  recently  well  described  by  Eibbert. 
The  triangular  shape  of  the  infarct  is  only  seen  when  it  involves  the  cortex 
and  medulla;  if  it  is  limited  to  the  cortex  it  is  quadrilateral  in  outline.  In 
the  small  infarcts  some  of  the  connective  tissue  and  some  of  the  tubules  may 
remain  alive.  A  t3q3ical  infarct  becomes  surrounded  by  three  zones:  an  inner 
and  white,  due  to  cell-infiltration;  a  middle  and  red,  due  to  hypersemia; 
and  an  outer  or  white,  due  to  partial  necrosis,  in  which  the  nuclei  are  earlier 
dissolved  than  elsewhere  because  of  the  presence  of  a  lymph-current.  The 
hyperasmic  zone  is  due  to  the  influx  of  blood  by  way  of  the  capillaries.  The 
cellular  infiltration  is  important  in  so  far  as  it  checks  the  influx  of  blood; 
the  outer  zone  remains  whitish  because'  of  the  partial  necrosis  and  because 
the  circulation  is  not  impeded.    An  aseptic  embolus  produces  disturbances  at 


396  PEINCIPLES    OF    SUEGERY. 

the  seat  of  impaction,  which  result  exclusively  from  the  sudden  interruption 
of  the  blood-supply  to  the  tissues  fed  by  the  obstructed  vessel.  The  effect  on 
the  tissues  is  the  same  as  though  the  vessel  had  been  tied  with  an  aseptic 
ligature.  Virchow  found  that  aseptic  caoutchouc  emboli,  introduced  into 
the  right  side  of  the  circulation  through  the  Jugular  vein,  produced  no  seri- 
ous trouble  after  their  impaction  in  the  branches  of  the  pulmonary  artery. 

Panum  ascertained,  by  his  experiments,  that  small,  simple  emboli  in  the 
pulmonary  artery  become  encysted.  The  emboli  of  foetal  cartilage  which 
Maas  introduced  into  the  jugular  vein  in  dogs  did  no  damage  to  the  pulmo- 
nary tissue,  and  not  only  retained  their  vitality,  but  became  the  nucleus  of 
a  temporary  tumor.  An  aseptic  embolus,  derived  from  plastic  intravascular 
exudations  or  an  aseptic  thrombus,  affects  the  tissues  at  the  seat  of  impac- 
tion in  the  same  manner  as  the  aseptic  substances  which  have  been  used  to 
produce  embolism  artificially  in  animals.  An  enibolus  consisting  of  a  frag- 
ment of  an  infected  thrombus,  as  is  the  case  in  pycemia,  is  a  culture-medium 
ivhich  contains  the  same  microbes  as  caused  the  primary  infection,  and  which 
at  the  seat  0/  impaction  establishes  an  independent  centre  of  infection,  which 
etiologically  and  pathologically  is  identical  with  the  primary  invasion. 

The  embolic  origin  of  metastatic  abscesses  was  first  pointed  out  by 
Virchow,  who,  at  the  same  time,  showed  that  the  emboli  are  always  derived 
from  venous  thrombi  undergoing  puriform  softening.  The  closure  of  a  ves- 
sel by  thrombosis  is  always  a  slow,  gradual  process,  while  the  obliteration  of 
an  artery  by  an  embolus  is  the  work  of  a  moment.  The  gradual  closure  of 
a  vessel  by  the  slow  growth  of  a  thrombus  is  not  attended  by  the^  same  degree 
of  disturbance  of  nutrition  as  when  a:  vessel  of  similar  size  is  suddenly  blocked 
by  the  impaction  of  an  embolus.  Septic  thrombophlebitis  does  not  lead  at 
once  to  embolism,  as  new  layers  are  constantly  being  added  to  the, proximal 
end  of  the  thrombus,  from  where  the  fragments  which  constitute  the  emboli 
are  always  derived.  Embolism  only  occurs  if  the  proximal  end  of  the  throm- 
bus has  become  sufficiently  softened  that  fragments  separate  spontaneously 
and  enter  the  venous  circulation,  or  if  the  fragments  are  washed  away  by  the 
venous  current  from  a  projecting  thrombus.  As  the  infected  thrombus  is 
always  located  in  a  vein  within,  or  in  close  proximity  to,  the  seat  of  primary 
infection,  the  detached  fragments  or  emboli  reach  the  right  side  of  the  heart 
with  the  venous  blood,  and,  as  they  are  usually  too  large  to  pass  through  the 
pulmonary  capillaries,  they  become  impacted  in  the  branches  of  the  pulmo- 
nary artery.  The  lung  acts  as  a  filter,  and  is  therefore  the  most  frequent  seat 
of  embolism  and  metastatic  abscesses.  The  circulatory  disturbances  at  the 
seat  of  impaction  give  rise  to  pathological  conditions  which  are  characteristic 
of  embolism,  and  can  be  readily  recognized  in  the  examination  of  organs 
after  death.  The  area  of  tissue  affected  by  the  sudden  closure  of  a  vessel  by 
the  impaction  of  an  embolus  is  called  an  infarct,  and  the  process  which  pro- 


ETIOLOGY.  397 

duced  the-  pathological  changes  infarction.  Infarcts  are  usually  wedge-shaped, 
the  apex  of  the  triangle  corresponding  to  the  location  of  the  embolus,  and  the 
base  to  the  ultimate  branches  of  the  obliterated  vessel. 

Cohnlieim  has  described  what  he  calls  a  terminal  artery,  by  which  is 
meant  one  whose  branches  inosculate  only  with  those  of  the  corresponding 
vein,  one  which  is  devoid  of  collateral  anastomosis.  Snch  are  the  renal  and 
splenic  arteries,  and,  in  a  less  complete  manner,  those  of  the  brain,  heart, 
stomach,  and  lungs.  If  a  terminal  artery  in  the  kidney  or  spleen  is  ob- 
structed collateral  circulation  cannot  be  established,  and  complete  or  partial 
necrosis  of  the  tissues  which  depend  on  the  closed  artery  for  their  blood- 
supply  is  an  inevitable  consequence."  The  same  result  follows  embolism  of 
a  terminal  artery  in  the  spleen.  In  the  other  organs  which  have  been  enu- 
merated the  terminal  arrangement  of  the  arteries  is  not  as  absolute,  and 


Fig.  149. — Embolus  of  Branch,  of  Pulmonary  Artery.    Haemorrhagic  infarction  of  alveoli. 
Chromic-acid  specimen.    1:100.     (Birch-Hirschfeld.) 

embolism  is  not  followed  by  necrosis  with  the  same  degree  of  certainty,  as 
circulation  can  be  restored,  under  favorable  cimcumstances,  by  collateral 
branches.  The  first  effect  of  the  closure  of  an  artery,  by  an  embolus  in  any 
of  these  organs,  is  the  appearance  of  a  wedge-shaped  area  of  ischsemia,  which 
in  size  corresponds  to  the  lumen  of  the  vessel  obstructed.  It  may  be  so  small 
that  it  can  hardly  be  detected  by  the  naked  eye,  or  the  base  of  the  wedge  may 
be  1  Va  inches  in  length.  The  border  of  this  wedge-shaped  space  becomes 
the  seat  of  active  hypergemia,  the  surrounding  vessels  undergoing  rapid  dila- 
tation. The  hyperemia  is  usually  so  intense  that  rhexis  takes  place  and  the 
parts  become  infiltrated  with  blood;  hence  the  expression  hcemorrhagic 
infarct. 

Hamilton'  is  of  the  opinion  that  the  hsemorrhagic  infarcts  in  the  lung 
are  not  caused  by  embolism,  but  by  rupture  of  small  vessels  and  hgemorrhage 


398 


PEINCIPLES    OP    SUEGEEY. 


into  the  alveoli,  the  distribution  of  the  tine  branches  of  the  bronchi  deter- 
mining the  shape  of  the  infarct.  Although  the  ultimate  branches  of  the 
pulmonary  artery  cannot  be  called  terminal  arteries,  in  the  strictest  sense 
implied  by  this  term,  if  they  become  suddenly  blocked  by  an  embolus,  col- 
lateral hypersemia  is  so  intense  that  liEemorrhage  into  the  parenchyma  of  the 
organ  frequently  takes  place:   a  condition  well  represented  in  Fig.  149. 


Fig.  150. — PyaBmic  Abscess  of  Lung.  A,  walls  of  alveoli;  B,  effused,  small,  round 
cells;  C,  fibrin  lying  in  alveolar  spaces;  D,  cell  entangled  in  meshes  of  same;  E,  E,  E, 
masses  of  micrococcus   (staphylococcus)   lying  in  exudation.     X  350.     {Hamilton.) 

In  hsemorrhagic  infarcts  of  the  lung  resulting  from  embolism  the  tissues 
involved  are  firmer  than  normal,  and,  on  section,  present  pneumonic  appear- 
ances, which  are  due  to  infiltration  with  leucocytes  and  extravasation  of 
blood,  as  well  as  transudation  of  blood-plasma  through  the  walls  of  the  hy- 


ETIOLOGY. 


399 


pereemic  blood-vessels  surroimding  the  iscligemic  area.  As  the  emboli  usually 
lodge  in  the  peripheral  branches  of  the  pulmonary  artery,  the  infarcts  are 
most  frequently  located  near  the  surface  of  the  lung.  Immediately  after 
embolism  has  occurred  the  district  supplied  by  the  obstructed  vessel  presents 
an  anaemic  appearance,  which  soon  gives  place  to  a  reddish  color,  resulting 
from  the  heemorrhagic  infiltration.  As  in  pyaemia  the  embolus  conveys  from 
the  primary  seat  of  infection  the  specific  microbes  of  suppuration,  it  becomes 
the  centre  of  a  suppurative  inflammation  (endoarthritis).  The  pus-microbes 
multiply  in  their  new  location  and  at  once  induce  a  suppurative  arteritis, 
and,  after  their  passage  through  the  inflamed  vessel-wall,  they  attack  the 
histological  elements  contained  in  the  exudation,  which  breaks  down,  be- 


Fig.  151.— Coagulation-necrosis  from  a  Kidney-infarct.  A,  zone  of  reactive  inflam- 
mation; B,  loss  of  nuclei  in  tlie  necrosed  epithelia.  (The  nuclei  of  connective-tissue 
cells  are,  in  part,  preserved.)     X  300.     {Birch-HirscTifeld.) 

comes  purulent,  and  is  converted  into  an  abscess.  In  the  lung  the  leucocytes 
which  are  present  in  the  infarct  are  converted  into  pus-corpuscles,  and  the 
interstitial  coniiective  tissue  undergoes  necrosis  and  can  be  found  as  detached 
shreds  in  the  abscess. 

Embolism  and  metastatic  abscesses,  although  most  frequently  found  in 
the  lungs  in  ^j^mia,  are  not  limited  to  this  organ.  To  explain  the  occur- 
rence of  embolism  in  more  remote  organs,  as  the  kidneys,  spleen,  liver,  brain, 
etc.,  we  must  assume  either  that  an  embolus  in  the  pulmonary  artery  becomes 
the  nucleus  of  a  thrombus,  which,  by  its  growth,  reaches  across  the  pulmo- 
nary capillaries  and  projects  into  the  pulmonary  vein,  where  fragments  again 
become  detached  and  enter  the  systemic  circulation,  or  zoogloea  of  pus-mi- 


400  PRINCIPLES    OF    SUEGEEY. 

probes,  passing  the  first  filter  (the  hmgs),  are  arrested  in  the  capillaries  of 
distant  organs,  or,  finally,  leucocytes  impregnated  with  pus-microbes  serve 
as  minute  emboli,  and,  after  their  localization  in  distant  organs,  become  the 
cause  of  metastatic  suppuration.  In  the  kidney  the  infarctions  appear  as 
sharply  circumscribed  areas  of  a  pale,  cream-yellow  color.  When  cut  into, 
the  infarct  has  a  wedge  shape  if  the  medullary  portion  is  involved,  the  nar- 
row end  pointing  to  the  hilus.  The  red  zone  is  not  so  marked  as  in  infarc- 
tions of  the  spleen,  and  the  greatest  vascularity  is  in  the  direction  of  the 
embolus.  As  in  infarcts  of  the  lung,  the  hyperasmic  zone  corresponds  to  the 
vessels  nearest  the  ischgemic  area.  Extravasation  of  blood,  although  present, 
is  never  so  marked  as  in  the  lung.  The  epithelial  cells  within  the  hypersemic 
zone  are  destroyed  by  coagulation-necrosis,  and  if  the  embolus  is  aseptic  this 
portion  of  the  kidney  is  removed  by  molecular  degeneration  and  absorption, 
leaving  a  cicatrix  behind. 

Infarcts  of  the  kidnej^  occurring  in  pygemia  are  converted  into  abscesses 
in  the  same  manner  as  in  the  lungs,  by  the  escape  of  pus-microbes  from  the 
embolus  through  the  inflamed  arterial  wall  into  the  tissues  starved  by  de- 
fective blood-supply. 

SYMPTOMS   AND    DIAGNOSIS. 

As  a  wound  complication  pygemia  never  occurs  before  suppuration  ha^ 
taken  place,  seldom  before  the  seventh,  usually  about  the  ninth  to  eleventh, 
day  after  the  accident  or  operation,  if  it  is  the  result  of  a  primary  infection 
of  the  wound.  In  patients  threatened  with  pyaemia  an  ill-defined  train  of 
premonitory  symptoms  precedes  the  actual  development  of  the  disease. 
These  symptoms  apply  to  the  appearance  of  the  wound  and  the  general  con- 
dition of  the  patient.  The  onset  of  the  disease  may  be  suspected  at  any  time 
after  suppuration  has  occurred,  when  evidences  of  serious  capillary  stasis 
manifest  themselves  at  the  seat  of  injury  or  operation.  The  thrombophle- 
bitis gives  rise  to  oedema;  the  margins  of  the  wound  appear  puffed  and  ele- 
vated, the  granulations  pale  and  fiabby;  suppuration,  which  may  have  been 
profuse,  becomes  scanty;  the  pus  changes  its  character,  and,  instead  of  a  yel- 
lowish, cream-colored  fiuid,  it  becomes  sanious,  serous,  or  sero-sanguinolent. 

Careful  inspection  of  the  parts  at  this  time  may  reveal  the  existence  of 
thrombosis  in  one  or  more  of  the  veins  leading  from  the  focus  of  primary 
infection.  The  general  premonitory  symptoms  are  indicated  by  a  slight  de- 
gree of  intoxication,  the  result  of  the  introduction  into  the  circulation  of 
pus-microbes  and  their  toxins,  from  the  primary  focus  of  suppuration,  caus- 
ing a  slight  rise  in  the  temperature  and  a  general  feeling  of  malaise,  thirst, 
and  loss  of  appetite.  The  actual  development  of  the  disease  is  initiated  by 
a  well-marked  severe  chill  or  rigor,  which  lasts  from  a  few  minutes  to  an 
hour  or  more.    The  chill  resembles  a  malarial  chill,  and  has  often  been  mis- 


SYMPTOMS    AND    DIAGNOSIS.  401 

taken  and  treated  as  such.  Such  a  chill  in  a  patient  suffering  from  a  sup- 
purating wound  or  abscess  is  always  an  alarming  symptom.  It  is  an  entirely 
subjective  symptom,  as  the  thermometer  placed  in  the  axilla  during  the  algid 
stage  indicates  a  rise  in  the  temperature,  which  often  reaches  104°  to  105° 
F.  before  the  patient  ceases  shivering. 

Chills  have  been  artificially  produced  in  animals  by  the  introduction  of 
foreign  substances  into  the  circulation,  and  in  pyemia  it  is  an  indication  that 
fragments  of  an  infected  thrombus,  and  with  them  a  large  quantity  of  pus- 
microbes,  have  entered  the  circulation.  The  chill  may  recur  at  regular  inter- 
vals daily  or  every  other  day:  a  feature  which  may  still  further  add  to  the  dif- 
ficulty in  making  a  differential  diagnosis  between  pygemia  and  malaria.  Usu- 
ally, however,  the  chill  recurs  at  irregular  intervals, — one,  two,  or  three  times 
a  day,  as  a  rule, — increasing  in  frequency,  and  often  in  intensity,  as  the  dis- 
ease progresses.  If,  for  instance,  during  the  first  few  days  the  patient  has 
one  chill  daily,  and,  after  a  few  days  two  or  more  during  the  same  time,  every 
additional  chill  indicates  a  more  advanced  stage  of  intoxication,  and  an  in- 
crease in  the  number  of  metastatic  foci.  After  the  chill  the  fever  continues 
for  several  hours,  with  a  temperature  of  103°  to  104°  F.,  until  the  appear- 
ance of  profuse  perspiration,  when  the  temperature  falls  to  normal,  or  even 
a  little  below  that.  The  chill,  fever,  and  sweating  coming  in  the  same  order 
and  of  about  the  same  duration  as  in  malaria.,  the  clinical  picture  resembles 
the  latter  almost  to  perfection,  and  on  this  account  many  cases  of  pygemia 
have  been  mistaken  in  the  beginning  for  malaria,  and  vice  versa. 

The  fever  which  attends  pyaemia  always  is  of  an  intermittent  or  remit- 
tent type.  In  acute  pyaemia  the  chills  may  return  several  times  during 
twenty-four  hours,  the  temperature  between  them  showing  remissions,  but 
seldom  returning  to  normal.  In  subacute  and  chronic  cases  the  remissions 
are  well  marked  between  the  chills,  the  temperature  often  sinking  below  nor- 
mal. Vomiting  and  diarrhoea  are  less  constant  symptoms  than  in  septicsemia. 
The  pulse  in  its  frequency  corresponds  to  the  temperature;  its  force  is  always 
reduced  by  the  depressing  effect  of  the  toxins  upon  the  heart.  Delirium  is 
occasionally  present,  but,  as  a  rule,  the  mind  is  clear  until  the  end.  The  yel- 
lowish color  of  the  skin,  almost  constantly  present  in  pygemia,  has  been  at- 
tributed to  icterus,  resulting  from  metastatic  processes  in  the  liver;  but  in 
the  majority  of  cases  it  is  not  the  result  of  retention  and  absorption  of  bile, 
but  is  caused  by  destruction  of  red  blood-corpuscles  and  pigmentation  of  the 
tissues  with  the  coloring  material  thus  liberated.  It  is  an  icterus,  which,  on 
account  of  its  origin,  is  called  "hcematogenous  icterus."  The  metastatic  de- 
posits in  the  kidneys  are  indicated  by  the  appearance  of  albumen  and  some- 
times pus  in  the  urine. 

Metastatic  Suppuration. — Infarcts  in  one  or  more  of  the  internal  organs 
are  present  in  every  case  of  pyaemia,  and  suppuration  in  some  of  the  large 


402  PRINCIPLES    OF    SUEGERY. 

cavities  is  of  frequent  occurrence.  In  reference  to  the  number  of  secondary 
metastatic  foci  of  suppuration,  a  great  deal  depends  on  the  clinical  form 
the  disease  assumes.  In  the  acute  variety,  which  proves  fatal  within  one 
to  three  weeks,  the  infarcts  are  numerous  and  the  abscesses  quite  small,  while 
in  some  of  the  infarcts  the  existence  of  suppuration  cannot  be  demonstrated 
macroscopically.  In  chronic  pysemia.,  in  which  life  is  prolonged  for  months, 
and  sometimes  even  a  year,  the  number  of  secondary  foci  are  few,  but  they 
have  resulted  in  the  formation  of  large  abscesses.  The  presence  of  infarcts 
of  the  lung  are  indicated  by  symptoms  and  signs  which  point  to  circum- 
scribed foci  of  inflammation  in  this  organ.  If  the  infarct  is  immediately  un- 
derneath the  pleura,  it  gives  rise  to  circumscribed  pleuritis  and  sharp,  lan- 
cinating pain  at  a  point  corresponding  to  the  location  of  the  infarct,  always 
aggravated  by  the  respiratory  movements.  In  such  eases  friction-sounds  can 
often  be  heard  over  the  infarct.  The  consolidation  of  the  tissues  involved  by 
the  infarct  by  inflammatory  infiltration  from  the  vessels  surrounding  it  is 
attended  by  crepitant  rales,  bronchial  breathing,  and  dullness  on  percussion, 
over  an  area  corresponding  to  the  size  of  the  infarct.  A  pulmonary  abscess 
which  takes  the  place  of  an  infarct  increases  in  size  by  encroaching  upon  the 
surrounding  tissues,  and  in  chronic  cases  may  empty  itself  into  a  bronchial 
tube.  A  subpleural  infarct,  infected  with  pus-microbes,  not  infrequently 
leads  to  suppurative  pleuritis  and  empyema  by  the  extension  of  the  infection 
from  the  lung-tissues  to  the  adjacent  pleura.  In  the  same  manner  a  suppu- 
rating infarct  of  the  lung  may  become  a  direct  cause  of  suppurative  pericar- 
ditis, and  pyopericardium  if  its  location  is  adjacent  to  the  pericardium.  The 
onset  of  metastatic  foci  in  the  lungs  is  often  insidious,  and  even  large  infarcts 
often  occasion  only  slight  subjective  symptoms  and  objective  signs.  Em- 
barrassed breathing  should  admonish  the  attendant  to  search  for  evidences 
of  multiple  infarcts  of  the  lung.  Abscesses  in  the  liver,  caused  by  septic 
emboli,  vary  in  size  from  that  of  a  pea  to  an  orange,  but  occasion  no  symp- 
toms unless  they  are  located  immediately  underneath  the  serous  covering, 
when  they  cause  localized  pain.  Embolic  infarcts  in  the  kidneys  may  be  sus- 
pected if  the  urine  contains  albumen  or  pus,  or  both.  The  spleen  is  always 
enlarged  in  pyemia,  but,  as  this  is  the  case  in  all  acute  infective  processes, 
the  presence  of  an  infarct  or  abscess  is  only  to  be  suspected  if  the  symptoms, 
especially  pain  and  circumscribed  tenderness,  point  to  the  existence  of  peri- 
splenitis. Enormous  pygemic  abscesses  often  develop  insidiously  and  with- 
out pain,  or  the  ordinary  symptoms  of  acute  inflammation  between  muscles 
and  in  the  subcutaneous  connective  tissue.  Metastatic  suppuration  in  py- 
emia takes  place  not  only  where  infarction  has  occurred,  but  also  in  localities 
where  the  existence  of  embolism  cannot  be  demonstrated  anatomically,  this 
being  notably  the  case  in  joints  and  the  large  serous  cavities.  Suppurative 
pericarditis,  pleuritis,  and  peritonitis  frequently  complicate  acute,  rapidly- 


SYMPTOMS    AND    DIAGNOSIS.  403 

fatal  pyaemia.  Suppurative  synovitis,  multiple  or  limited  to  one  joint,  is  a 
frequent  complication,  both  in  acute  and  chronic  pyemia.  Metastatic  sup- 
puration in  these  localities  develops  without  demonstrable  .infarcts,  and  oc- 
curs, in  all  probability,  in  consequence  of  mural  implantation  of  pus-mi- 
crobes or  infected  leucocytes  upon  the  wall  of  capillary  vessels,  the  intima 
of  which  has  been  damaged  by  toxins  held  in  solution  by  the  circulating 
blood.  As  in  all  cases  of  pyaemia  pus-microbes  and  their  toxins  necessarily 
constantly  enter  the  circulation  from  the  primary  focus  of  infection,  they 
prepare  the  soil  for  the  reception  and  pathogenic  action  of  pus-microbes  in 
the  vessels  and  tissues  of  certain  organs,  more  especially  the  synovial  mem- 
brane of  joints  and  the  serous  membranes  lining  the  large  cavities.  Pygemic 
abscesses,  when  well  developed,  always  contain  yellow  pus  of  the  consistence 
of  cream.  Examined  under  the  microscope,  such  pus  contains  corpuscles 
in  which  no  sign  of  a  nucleus  can  be  found. 


Fig.   152. — PyEemic   Pus,    showing   Complete   Nuclear  Destruction  in   Corpuscles  and   an 
Abundance  of  Pus-microbes  witMn  and  between  Pus-corpuscles.     (Landerer.) 

The  pus-microbes  are  always  present  in  great  numbers,  both  within  the 
pus-corpuscles  and  in  the  pus-serum.  While  some  doubt  may  remain  after 
the  first  chill  as  to  the  nature  of  the  disease,  this  doubt  is  dispelled  with  the 
recurrence  of  the  chills.  In  acute  cases  the  chill  returns  once  or  twice  daily, 
but,  unlike  in  cases  of  malaria,  if  the  chill  is  of  daily  occurrence,  it  does  not 
come  at  a  fixed  time,  as  is  the  case  in  the  latter.  If  the  disease  does  not 
culminate  into  a  daily  chill,  the  temperature  then  shows  an  irregular  remit- 
tent type  of  fever.  The  patient  loses  strength  and  flesh  rapidly,  and  the  face 
presents  the  color  of  a  mixture  of  the  hectic  flush  with  the  icteric  hue.  While 
the  pulse  at  first  rises  only  to  100  to  120  beats  per  minute  during  the  febrile 
exacerbations,  it  soon  remains  at  from  120  to  150  per  minute.  Great  thirst 
and  complete  loss  of  appetite  remain  constant  symptoms.  The  tongue  and 
lips  are  dry,  diarrhcea  is  more  common  as  septic  intoxication  advances,  and 
the  stools  are  frequently  stained  with  blood.  As  the  fatal  termination  ap- 
proaches, delirium  and  sopor  come  on,  and  under  increasing  symptoms  of 
depression  death  takes  place  gradually  from  heart-failure,  or  suddenly  from 
embolism  of  the  pulmonary  artery.    In  chronic  cases  the  duration  of  the  dis- 


404  PEINCIPLES    OF    SURGERY. 

ease  is  sometimes  prolonged  for  months,  and  Billrotli  relates  a  case  where  the 
patient  lived  for  a  year.  In  chronic  cases  the  chills  recur  at  long  intervals, 
and  the  fever  assumes  a  remittent  type  between  them.  In  still  another  class 
of  chronic  pysemia  the  chills  ultimately  disappear,  and  the  fever  assumes  a 
mild,  continuous  type,  while  the  patient  gradually  succumbs  to  decubitus, 
amyloid  degeneration  of  internal  organs,  or  a  slow  form  of  septic  intoxica- 
tion. 

PROGNOSIS. 

The  prognosis  of  pygemia  is  always  grave.  Acute  pysemia,  in  spite  of  all 
treatment,  almost  without  exception  terminates  in  death  in  from  one  to  two 
weeks.  The  few  recoveries  which  have  been  reported  were  cases  of  subacute 
or  chronic  pysemia.  As  pyemia  is  not  a  primary,  but  secondary,  condition, 
it  is  a  fatal  disease  from  the  very  beginning,  as  during  its  commencement 
transportation  of  infected  tissue  has  taken  place  to  localities  usually  inac- 
cessible to  radical  treatment.  In  acute  cases  death  seldom  takes  place  before 
the  end  of  the  first  week,  more  frequently  from  the  second  to  the  endof  the 
third  week.  Chronic  cases  not  complicated  by  pulmonary  infarcts,  the 
metastatic  suppuration  in  parts  accessible  to  surgical  treatment,  are  occasion- 
ally amenable  to  successful  treatment,  and  a  cure  can  be  obtained  after  a  long 
and  lingering  illness.  Prospects  of  a  successful  issue  in  chronic  cases  can  be 
only  entertained  when  the  disease  attacks  young  individuals  otherwise  in 
good  health.  The  prognosis  of  pysemia  is  also  modified  by  the  location  of 
the  primary  focus  of  infection,  as  when  this  is  not  accessible  to  direct  treat- 
ment the  disease  will  progress  uninfluenced  by  general  treatment.  If,  on 
the  other  hand,  further  supply  of  septic  material  from  the  primary  inf ection- 
:atrium  can  be  prevented  by  a  prompt  removal  of  the  infected  tissues,  one  of 
the  most  important  indications  of  treatment  has  been  met,  and  the  hope  of 
&  favorable  termination  has  been  thereby  increased. 

PATHOLOGICAL    ANATOMY. 

The  pathological  changes  found  in  patients  who  have  died  of  pysemia 
are  characteristic.  The  primary  focus  of  infection  may  no  longer  be  present, 
as  it  may  have  healed,  but,  as  a  rule,  this  has  not  occurred,  and  examination 
shows  a  suppurating  wound,  an  abscess,  an  osteomyelitic  focus,  a  suppurating 
phlebitis  or  sinus  phlebitis.  The  vein  in  which  the  fatal  thrombus  formed 
may  not  be  a  large  one;  indeed,  it  may  be  so  small  as  to  elude  detection  by 
macroscopical  examination.  If  the  immediate  cause  of  the  pysemia,  the 
thrombosed  vein,  can  be  located,  it  will  be  found  filled  with  a  softened,  loose 
blood-clot,  which  is  very  variable  in  length,  and  the  proximal  end  of  which 
projects  usually  into  the  lumen  of  some  larger  vein-trunk  on  the  proximal 
side.    The  vein-wall  itself  is  in  a  state  of  suppurative  infiammation  that  pre- 


PATHOLOGICAL    ANATOMY.  405 

vents  the  formation  of  firm  adhesions  between  the  thrombus  and  the  intima, 
as  we  find  it  in  cases  of  plastic  thrombophlebitis.  The  new  histological  ele- 
ments that  are  produced  by  the  inflammatory  process  are  at  once  converted 
into  pus-corpuscles,  and  some  of  these  are  distributed  through  the  substance 
of  the  blood-clot,  and  furnish  an  additional  cause  for  the  softening  and  dis- 
integration of  the  coagulum.  The  infarcts  are  most  numerous  in  the  lungs, 
but  are  also  found  in  the  spleen,  kidneys,  and  liver.  An  embolus  catches  in 
an  artery  at  a  point  where  the  lumen  suddenly  becomes  smaller,  which  is  the 
case  where  the  vessel  bifurcates.  The  embolus,  after  it  has  become  impacted, 
becomes  the  nucleus  of  a  thrombus,  as  the  blood  which  comes  in  contact  with 
it  undergoes  coagulation,,  and  in  this  manner  layer  after  layer  is  added  on 
each  side.  As  the  embolus  under  these  circumstances  is  always  composed  of 
dead,  infected  material,  it  causes,  at  the  seat  of  impaction,  a  specific  inflam- 
mation, which,  in  every  respect,  represents  the  type  of  inflammation  at  the 
primary  seat  of  infection.  As  the  tissues  luhich  are  in  immediate  contact  with 
the  embolus  are  the  coats  -of  an  artery,  a  suppurative  arteritis  follows  the  im- 
paction, and,  as  soon  as  the  pus-microbes  have  passed  through  the  softened, 
inflamed  arterial  wall,  the  infection  extends  to  the  tissues  weakened  by  the 
sudden  abstraction  of  blood;  that  is,  the  tissues  which  are  within  the  borders 
of  the  wedge-shaped  infarct.  The  hypersemic  zone  around  the  infarct  con- 
stitutes a  wall  of  protection  against  unlimited  extension  of  the  infection  and 
inflammation.  In  the  lungs  the  infarct  becomes  rapidly  infiltrated  with  the 
products  of  inflammation  from  the  hypergemic  zone,  which  gives  rise  to  con- 
solidation of  that  portion  of  the  lung.  Suppuration  is  attended  by  liquefac- 
tion of  the  exudation,  and  the  infarct  is  transformed  into  an  abscess. 

In  pygemia  the  emboli  that  reach  the  systemic  circulation  are  smaller 
than  those  which  reach  the  pulmonary  artery;  consequently  the  infarcts,  as 
a  rule,  in  the  kidney,  spleen,  liver,  and  other  distant  organs  are  smaller  than 
those  in  the  lungs.  In  metastatic  suppuration  without  embolism,  in  the 
strict  sense  in  which  this  word  has  been  heretofore  used,  the  pus-microbes 
which  become  implanted  upon  capillary  walls,  changed  by  the  action  of- 
preexisting  toxins  diffused  in  the  blood,  reach  and  infect  the  paravascular 
tissues  and  the  interior  of  large  cavities,  thus  causing  a  rapidly-spreading, 
diffuse,  suppurative  inflammation.  In  metastatic  suppurative  inflammation 
of  the  synovial  membrane  of  joints,  the  peritoneum,  pleura,  and  pericardium, 
the  process  represents  all  the  essential  features  of  a  speciflc  surface  inflam- 
mation, characterized  by  rapid  extension  of  the  inflammation  over  the  whole 
surface  and  the  accumulation  of  a  large,  purulent  collection  in  a  short  time. 
Microscopical  examination  of  nearly  all  organs  in  fatal  cases  of  pysemia  re- 
veals the  existence  of  coagulation-necrosis  resulting  from  the  action  of  pus- 
microbes  and  their  toxins  upon  tissues  with  which  they  have  been  brought 
in  direct  contact.     The  spleen  is  always  enlarged  and  softened,  even  if  no 


406  PEINCIPLES    OF    SUEGERY. 

infarcts  are  present.  The  heart  is  flabby  and  the  muscular  tissue  softened. 
The  intestinal  mucous  membrane  is  swollen,  vascular,  softened,  and  at  points 
shows  submucous  extravasation  from  rupture  of  capillary  vessels, — evidences 
that  this  structure  has  also  become  the  seat  of  metastatic  inflammation.  Em- 
bolism of  cerebral  vessels  is  an  unusual  occurrence  in  pyaemia,  while  they  are 
frequently  obstructed  by  emboli  which  become  detached  from  valvular  vege- 
tations in  the  left  side  of  the  heart. 

TREATMENT. 

Before  the  use  of  antiseptics  in  surgery  pygemia  figured  largely  as  the 
cause  of  death  after  injuries  and  operations.  Only  thirty  years  ago  a  large 
percentage  of  the  surgical  patients  in  the  old,  infected,  European  hospitals 
died  from  this  disease.  Insignificant  injuries  and  minor  operations  were  fre- 
quently followed  by  this  fatal  complication.  At  present  it  is  a  source  of  pride 
to  the  teachers  of  surgery  if,  during  a  course  of  lectures,  they  do  not  succeed 
in  finding  a  case  for  clinical  study  and  instruction.  In  hospitals  where  anti- 
septic surgery  is  thoroughly  and  conscientiously  practiced  the  disease  is  al- 
most unknown.  Helpless  as  we  still  are  in  curing  the  disease,  as  surely  can 
we  prevent  it,  in  the  management  of  recent  injuries  or  intentional  wounds, 
if  we  resort  to  careful  and  efficient  antiseptic  and  aseptic  precautions.  The 
prevention  of  suppuration  in  a  wound  furnishes  absolute  protection  against 
pycemia.  Again,  the  early  radical  treatment  of  suppurative  lesions  has  been 
the  means  of  diminishing  the  frequency  of  pysemia  from  causes  other  than 
wounds.  The  prophylactic  treatment  of  pycemia  consists  in  preventing  sup- 
puration in  wounds  hy  antiseptic  means,  amd  in  sterilizing  suppurating  foci 
before  septic  thrombophlebitis  has  occurred  by  early  incision,  antiseptic  irriga- 
tion, drainage,  and  in  maintaining  asepticity  under  antiseptic  dressings. 

In  the  treatment  of  suppurating  wounds  a  great  deal  can  be  done  toward 
the  prevention  of  pygemia  by  resorting  to  thorough  secondary  disinfection, 
and  in  guarding  against  tension  and  accumulation  of  the  products  of  septic 
.inflammation  by  efficient  drainage,  or,  still  better,  by  combining  drainage 
with  permanent  irrigation.  Suppurative  osteomyelitis  should  be  treated  by 
early  operative  measures,  not  only  for  the  purpose  of  preventing  unnecessary 
destruction  of  bone  and  of  relieving  pain,  but  more  particularly  with  a  view 
of  warding  off  this  fatal  complication.  Klebs  made  the  suggestion  to  sur- 
geons that  the  prophylactic  treatment  of  pj^semia  should  be  carried  still 
further,  by  excising  such  veins  as  are  known  to  contain  infected  thrombi  be- 
fore embolism  has  taken  place.  The  same  suggestion  was  made  by  Zaufel 
in  1880,  who  proposed  ligation  of  the  internal  jugular  vein  as  a  prophylactic 
measure  against  pysemia  in  cases  of  phlebitis  of  the  lateral  sinus  complicating 
septic  inflammation  of  the  middle  ear.  To  Lane  belongs  the  credit  of  hav- 
ing first  applied  this  suggestion  in  practice.     The  justifiability  and  advis- 


TKEATMENT.  407 

ability  of  such  treatment  cannot  be  doubted,  and  surgeons  will  be  glad  to 
adopt  this  suggestion  in  cases  where  it  is  possible  to  ascertain  the  location 
of  the  thrombosed  vein  or  veins,  and  where  such  an  operation  is  feasible  on 
anatomical  grounds.  A  number  of  successful  curative  operations  have  been 
performed  during  the  last  few  years  in  cases  of  incipient  pyasmia  following 
thrombophlebitis  of  the  sigmoid  sinus  in  cases  of  suppurative  inflammation 
of  the  middle  ear.  The  operation  consists  in  ligating  the  internal  jugular 
vein  on  the  corresponding  side  below  the  thrombus  if  this  has  extended  to 
the  vein,  and  in  exposing  and  removing  the  suppurating  thrombus  from  the 
sinus.  This  operation  should  be  performed  in  every  case  of  suppuration 
of  the  middle  ear  as  soon  as  this  complication  can  be  recognized.  Salzer 
■operated  on  two  such  cases  by  opening  the  lateral  sinus  and  removing  the 
septic  thrombus,  and  one  of  his  cases  I'ecovered.  Keen  in  addition  ligated 
and  divided  the  internal  Jugular  vein  on  the  corresponding  side  below  the 
thrombus  which  had  formed  in  it,  but  his  patient  died.  The  most  charac- 
teristic symptoms  of  septic  thrombosis  of  the  lateral  sinus  are:  tenderness 
along  the  course  of  the  internal  Jugular  vein,  evidences  of  disturbed  circula- 
tion in  the  region  of  the  ear,  and,  if  the  thrombosis  has  extended  to  the  in- 
ternal Jugular  vein,  emptiness  of  the  vein  below  the  thrombus.  Puncture 
with  the  needle  of  an  hypodermic  syringe  will  show  at  once  whether  the 
lumen  of  the  sinus  is  occluded.  In  grave  cases  of  osteomyelitis  an  opera- 
tion for  this  special  indication  would  often  make  it  necessary  to  amputate, 
as  even  the  most  thorough  scraping  out  of  the  infected  medullary  cavity 
might  fail  in  removing  all  of  the  infected  thrombi.  It  has  also  been  sug- 
gested to  interrupt  the  venous  circulation  in  one  of  the  principal  venous 
trunks  of  a  limb  by  ligation,  for  the  purpose  of  preventing  mechanically  the 
entrance  of  detached  fragments  of  a  thrombus  into  the  circulation;  but  this 
procedure  has  not  answered  the  expectations,  as  the  emboli  will  reach  the 
general  circulation  through  collateral  branches.  Eemoval  of  the  infected 
thrombi  by  amputation  or  resection  of  the  affected  portion  of  a  vein  are 
more  reliable  prophylactic  measures  than  ligation  in  the  continuity  of  a 
principal  vein-trunk  on  the  proximal  side. of  the  primary  seat  of  infection. 
Detachment  of  fragments  of  a  disintegrating  thrombus  must  be  prevented  as 
far  as  possible  by  securing  absolute  rest  for  the  infected  part,  as  all  sudden 
movements,  active  and  passive,  and  sudden  disturbances  of  the  circulation 
may  become  the  means  of  separation  of  fragments,  and  their  transportation 
as  emboli  into  the  circulation.  The  curative  treatment  of  pysemia,  medical 
and  surgical,  is  unsatisfactory.  Quinine,  natrum  benzoicum,  and  the  dif- 
ferent preparations  of  salicylic  acid  have  been  used  quite  extensively  in  the 
treatment  of  the  fever  which  attends  the  disease.  Antifehrin,  antipyrin, 
and  other  drugs  'of  the  same  class  of  remedies  are  worse  than  useless,  as  the 
favorable  effects  from  their  antipyretic  action  are  more  than  overbalanced  hy 


408  PKINCIPLES    OF    SUEGERY. 

tlie  harm  they  do  in  depressing  the  action  of  the  heart.  External  heat  and  the 
internal  administration  of  diffusible  stimulants  should  be  used  to  shorten 
the  duration  of  the  rigors.  Alcohol  stimulants  are  indicated  in  the  acute  and 
chronic  forms  of  the  disease. 

In  chronic  pyaemia  a  daily  tepid  bath  is  of  the  greatest  value.  In  the 
same  class  of  cases  it  is  of  the  utmost  importance  to  support  the  patient's 
strength  by  systematic  feeding  and  the  use  of  the  malt  beverages,  such  as 
beer,  ale,  and  porter,  with  a  view  of  prolonging  life  until  the  microbic  cause 
is  eliminated  from  the  primary  and  secondary  depots  of  infection,  spontane- 
ously or  by  surgical  treatment.  In  acute  cases  of  pygemia,  originating  from 
a  wound  of  one  of  the  extremities,  or  from  acute  suppurative  osteomyelitis 
of  .the  long  bones,  the  question  of  removal  of  the  primary  focus  of  infection 
by  amputation  will  present  itself. 

If,  from  a  study  of  the  symptoms,  it  become  apparent  that  multiple 
infarcts  exist  in  the  lungs,  and  other  organs,  amputation  is  not  permis- 
sible, as  it  would  only  result  in  shortening  the  life  of  the  patient.  The 
propriety  of  an  amputation  should  only  he  considered  in  the  beginning  of  the 
disease,  and  before  extensive  dissemination  of  tlu-  purulent  infection  by  em- 
holism  has  tahen  place.  In  a  suppurating,  compound  fracture,  amputation 
may  be  indicated  for  other  reasons  than  those  of  a  threatened  or  developed 
attack  of  pyeemia.  Secondary  disinfection  of  a  suppurating  tvound  ivith  ex- 
cision 'of  thromhophlehitic  veins,  where  this  is  possible,  should  be  practiced 
in  all  cases  of  pycemia  for  the  purpose  of  preventing  or  limiting  general  dis- 
semination by  embolism.  In  chronic  cases  the  secondary  metastatic  proc- 
esses should  receive  early  and  careful  attention. 

As  in  these  cases  the  metastatic  suppuration,  as  a  rule,  is  not  caused 
by  embolic  infarcts,  life  is  threatened  by  the  secondary  lesions,  from  which 
intoxication  is  maintained,  and  from  which  new  places  may  become  infected 
by  localization  of  pus-microbes  in  capillary  vessels  weakened  by  the  action 
of  toxins.  If  the  metastasis  is  limited  to  one  or  more  joints  and  the  disease 
pursue  a  chronic  course,  very  satisfactory  results  can  be  obtained  by  tapping 
and  washing  out  the  joints  with  a  3-per-cent.  solution  of  carbolic  acid.  The 
tapping  and  irrigation  should  be  repeated  as  often  as  the  effusion  returns. 
In  a  case  of  genuine  pysemia  following  a  gunshot  wound  of  the  leg,  compli- 
cated by  secondary  heemorrhage  and  gangrene,  that  recently  came  under  my 
observation,  I  performed  amputation  and  later  tapped  both  shoulder-joints 
and  the  left  sternoarticular  joint  repeatedly  and  followed  the  tapping  in  each 
instance  by  antiseptic  irrigation.  The  patient  finally  recovered,  and  the 
joints  thus  treated  were  movable.  For  thirty-five  days  he  consumed,  on  an 
average,  a  quart  of  whisky  daily,  and  I  attribute  the  favorable  result  largely 
to  this  energetic  stimulation.  Suppurating  joints  are  incised,  drained,  and 
irrigated  under  strict  antiseptic  precautions,  and,  if  the  metastatic  suppura- 


SEPTOPY^MIA.  409 

tion  is  limited  to  a  single  joint,  this  can  be  done  with  a  fair  prospect  of  a 
favorable  result.  Purulent  collections  in  the  serous  cavities  or  connective 
tissue  are  dealt  with  in  a  similar  manner.  Careful  attention  to  diet  and  the 
sanitary  surroundings  of  the  patient,  combined  with  energetic  surgical  treat- 
ment of  the  suppurating  foci,  will,  at  least  occasionally,  be  rewarded  by  an 
ultimate  recovery. 

SEPTOPYiEMIA. 

In  the  absence  of  more  accurate  knowledge  concerning  the  microbic 
cause  of  septicaamia,  we  must,  at  least  for  the  present,  assign  to  septicaemia 
and  pyEemia  the  same  bacteriological  cause.  That  pus-microbes  can  produce 
septicgemia  when  introduced  into  the  circulation  in  sufficient  quantity  has 
already  been  shown,  and  that  pus-microbes  have  been  frequently  cultivated 
from  septic  products  is  a  matter  of  demonstration;  hence  the  disease,  if  not 
identical  with  pygemia,  from  a  bacteriological  stand-point,  is  at  any  rate 
closely  allied  to  it.  It  has  also  been  shown  that,  in  case  the  life  of  a  septic 
patient  is  prolonged  for  a  sufficient  length  of  time,  the  metastatic  foci  of 
inflammation  are  the  seat  of  incipient  suppuration;  hence  such  cases  re- 
semble pysemia  upon  a  pathological  basis.  In  pyaemia,  after  cessation  of  the 
rigors,  which  are  the  most  characteristic  clinical  symptom  of  this  disease,  the 
fever  resembles  septicgemia,  and,  as  the  clinical  picture  thus  developed  rests 
upon  pathological  conditions  typical  of  pygemia,  it  would  be  proper  to  apply 
to  such  cases  the  term  septopijcemia.  For  the  same  etiological  and  patho- 
logical reasons  we  apply  the  same  term  to  septicaemia  in  which  post-mortem 
examination  reveals  the  presence  of  minute,  multiple,  suppurating  foci. 

Septopygemia  may  be  defined  as  a  condition  in  which  the  symptoms 
indicate  the  presence  of  both  septicaemia  and  pyaemia  and  in  which  the  post- 
mortem appearances  point  to  septic  and  purulent  infection.  Leube  de- 
scribed such  a  combination  of  the  two  diseases,  which  as  yet  are  considered 
as  distinct,  occurring  in  patients  in  whom  he  was  unable  to  trace  the  source 
of  infection  from  without;  hence  he  called  the  affection  spontaneous  sep- 
tico-pycemia.  Litten,  on  the  other  hand,  in  similar  cases,  was  always  able  to 
locate  the  infection-atrium,  but  the  primary  infection  at  the  time  acute 
symptoms  set  in  had  either  disappeared  or  its  location  could  only  be  ascer- 
tained by  most  careful  examination.  Jlirgensen  applied  to  these  cases  the 
lengthy  compound  word  "kryptog&n^tic-septico-pycemia,"  as  he  was  unable 
to  find  a  tangible  infection-atrium.  In  an  article  on  the  subject  he  gives 
an  account  of  100  cases  that  came  imder  his  own  personal  observation.  The 
patients  were  usually  attacked  first  with  acute  pharyngitis,  and,  as  this  stage 
was  generally  attended  by  a  chill  and  a  general  feeling  of  malaise,  the  pa- 
tients usually  attributed  the  onset  of  the  disease  to  exposure  to  cold.  In  most 
cases  the  general  infection  was  announced  by  a  severe  chill.    Eapid  loss  of 


410  PRINCIPLES    OF    SURGERY. 

strength  was  one  of  the  most  prominent  symptoms;  the  patients  in  a  few 
hours  after  the  chill  became  utterly  prostrated.  The  symptoms  which 
pointed  to  local  processes  during  life  were  referred  most  frequently  to  the 
lungs,  liver,  spleen,  pleura,  heart,  and  the  long  bones.  Whether  the  primary 
affection  occurred  through  the  pharynx,  where  the  first  symptoms  were 
manifested,  could  not  be  definitely  ascertained.  In  the  acute  cases  the  symp- 
toms were  grave  from  the  beginning  and  increased  in  intensity  as  the  infec- 
tion progressed,  while,  in  the  chronic  cases,  infection  is  kept  up  from  some 
suppurating  focus,  and  the  disease  may  continue  for  several  years.  Subcu- 
taneous and  retinal  hemorrhagic  extravasations  were  frequently  observed. 
Post-mortem  examinations  revealed  suppuration  in  some  of  the  internal  or- 
gans, and  vascular  changes  which  are  characteristic  of  sepsis. 

These  cases  may  be  compared  with  acute  suppurative  osteomyelitis, 
where,  after  the  most  careful  inquiry  and  the  most  scrutinizing  examination, 
we  often  fail  in  furnishing  reliable  evidence  for  locating  the  primary  source 
of  infection.  It  is  possible  that  the  pus-microbes  enter  through  an  intact 
or  inflamed  mucous  membrane,  or  through  the  appendages  of  the  skin,  and 
that  they  remain  in  a  latent,  inactive  condition  until  a  weak  point  is  created 
somewhere  in  the  body,  where  they  localize  in  a  soil  prepared  for  their  re- 
production and  pathogenic  action;  or,  what  is  more  likely  the  case,  they 
enter  through  an  abrasion  or  slight  lesion,  which  may  be  so  insignificant 
that  the  patient  himself  fails  to  notice  it,  and  produce  no  symptoms  until, 
by  accident  or  disease,  a  proper  soil  is  prepared  for  the  initiation  of  an  acut€ 
attack  in  one  or  more  of  the  internal  organs.  The  remote  dangers  which 
may  follow  infection  through  an  insignificant  wound,  or  from  a  small,  sup- 
purating focus,  should  remind  the  surgeon  of  the  importance  of  treating 
these  little  ailments  with  the  necessary  care  and  attention,  and  by  so  doing 
he  will  often  be  the  means  of  preventing  fatal  complications.  In  two  cases 
of  cryptogenetic  septopysemia  that  have  come  under  my  own  observation 
the  disease  was  complicated  by  ulcerative  endocarditis.  In  one  of  these  cases 
the  immediate  cause  of  death  was  gangrene  from  embolism  of  the  popliteal 
artery. 


CHAPTER  XVI. 

Erysipelas. 

Eetsipelas  is  a  self-limited,  acute,  non-suppurative  inflammation  of 
the  lymphatic  vessels  of  the  skin  or  mucous  membrane,  attended  b}^  redness 
and  a  continued  type  of  fever.  As  a  wound  complication  it  occurs  independ- 
ently of  suppuration,  and  in  its  uncomplicated  pure  form  remains  as  a  super- 
ficial affection,  the  inflammation  never  passing  beyond  the  structures  of  the 
skin  or  mucous  membrane. 

HISTORY    OF    ITS    MICROBIC    ORIGIN. 

The  contagiousness  of  erysipelas  has  been  recognized  for  centuries,  and 
on  this  account  early  attempts  were  made  to  include  it  among  microbic  dis- 
eases. In  1868  Hueter  maintained  that  erysipelas  and  hospital  gangrene 
were  identical  diseases  and  caused  hj  the  same  microorganism.  Its  microbic 
nature  was  again  made  the  subject  of  investigation  in  1872,  when  ISTepveau 
discovered  micrococci  in  the  blood  of  erysipelatous  patients.  Wilde  detected 
the  same  microbes  in  the  blood,  but  asserted  that  similar  microorganisms 
could  be  found  in  the  pus  in  wounds  from  which  the  erysipelas  developed. 

In  1871:  Eecklinghausen  found  masses  of  micrococci  in  the  lymphatic 
channels  in  the  inflamed  skin  at  the  border  of  an  erysipelatous  inflammation. 
Xearly  the  same  time  similar  observations  were  made  by  Billroth,  Ehrlich, 
Tillmanns,  and  Koch.  Tillmanns  produced  the  disease  artificially  in  ani- 
mals by  injecting  subcutaneously  the  serum  contained  in  the  bullae  of  ery- 
sipelatous skin. 

Koch  attempted  to  produce  the  disease  artificially  in  rabbits  with  in- 
jections of  different  putrid  fluids,  but  failed  until  he  made  inoculations  with 
mouse-dung  softened  in  distilled  water.  He  injected  the  material  under  the 
skin  of  the  ear,  and  produced  an  inflammation  which  in  its  course  resembled 
erysipelas.  The  swelling  and  redness  spread  slowly  downward  from  the  point 
of  inoculation.  On  the  fifth  day  it  had  extended  as  far  as  the  root  of  the 
ear.  The  ear  became  exceedingly  vascular,  so  that  the  separate  vessels  could 
no  longer  be  identified,  while  the  tissues  were  softened  and  oedematous.  The 
animal  died  on  the  seventh  day.  Blood  taken  from  the  heart  of  this  animal 
produced  no  effect  in  other  rabbits.  No  microbes  could  be  found  in  the 
blood  or  in  any  other  organ  except  the  affected  ear.  In  transverse  sections 
of  the  ear  the  blood-vessels  were  seen  to  be  markedly  dilated,  full  of  red 
corpuscles,  and  surrounded  by  the  nuclei  of  white  corpuscles.  Between  these 
and  the  cartilage-cells  bacilli  were  found. 

The  bacilli  were  present  close  to  the  cartilage  only.     Here  they  were 

(411) 


412 


PRINCIPLES    OF    SURGERY. 


found  in  large  clusters,  from  which  the  bacilli  radiate  in  all  directions.  This 
net-work  of  bacilli  extended  over  the  whole  cartilage  of  the  ear  on  both  sur- 
faces. Inflammation  was  most  marked  in  the  vicinity  of  the  bacilli,  and, 
consequently,  in  the  absence  of  other  causes,  there  could  be  no  doubt  that 
the  erysipelatous  inflammation  was  caused  by  these  microbes.  Orth  found 
micrococci  in  the  contents  of  the  bullse  of  erysipelas.     Eecklinghausen  and 


Fig.  153. — Section  of  Ear  of  Rabbit  Parallel  to  Surface  of  Cartilage.  The  morbid 
process  resembled  erysipelas.  A,  balli-like  accumulation  of  bacilli;  B,  accumulation  of 
nuclei  above  the  layer  of  bacilli;  C,  nuclei  of  flat  cells  connected  with  the  cartilage 
below  the  layer  of  bacilli;    D,  bacilli  arranged  parallel  to  each  other.     X  700.     (Koch.)^ 


Lukowsky  found  them  in  the  lymphatic  vessels  and  the  connective-tissue 
spaces  in  the  structures  affected  by  erysipelas.  Billroth  and  Ehrlich  found 
bacteria  not  only  in  the  lymphatic  channels,  but  also  in  the  blood-vessels  of 
the  inflamed  skin.    Tillmanns  found  microbes  in  erysipelatous  skin,  and  Let- 


1  Copied   from    "Traumatic   Infective    Diseases,"    by   permission   of   the    New    Sydenham 
Society,  London. 


CULTIVATION.  413 

zerich,  in  cases  of  erysipelas  attacking  vaccination  wounds,  found  them  in 
the  wound  itself,  in  the  blood-vessels,  muscles,  liver,  spleen,  and  kidneys. 
The  essential  specific  cause  of  erysipelas  was  finally  discovered  by  Fehleisen 
in  1883.  He  cultivated  the  microbe  from  erysipelatous  products,  and  dem- 
onstrated its  essential  etiological  relationship  to  erysipelas  by  producing  the 
disease  artificially,  in  animals  and  man,  by  inoculations  with  pure  cultures. 
From  the  morphological  appearance  of  the  microbe  and  its  direct  etiological 
bearing  to  erysipelas  he  called  it  the  streptococcus  of  erysipelas.  With  pure 
cultures  of  this  microbe  he  produced  by  inoculations  not- only  erysipelas  in 
animals,  to  prove  its  specific  pathogenic  qualities,  but  successful  inoculations 
were  also  made  in  man  for  therapeutic  purposes. 

DESCRIPTION"    OF    STEEPTOCOCCUS    ERYSIPELATOSUS. 

The  streptococcus  erysipelatosus,  discovered  by  Fehleisen,  when  exam- 
ined under  the  microscope  appears  in  the  form  of  chains,  the  links  of  which 
are  minute  cocci,  3  to  4  micromillimetres  in  diameter. 


.:t-..«* 


Fig.   154.— Streptococcus  Erysipelatosus.     Pure  culture  in  bouillon   at  37°  C, 
stained  with  fuchsin.     X  950.     (Baumgarten.) 

The  streptococcus  of  erysipelas  invades  the  superficial  lymphatic  chan- 
nels of  the  skin  or  mucous  membrane  exclusively,  but  it  can  also  be  found 
in  the  serum  contained  in  bullae.  Each  coccus,  when  it  is  about  to  divide, 
becomes  larger  and  oval,  and  soon  appears  made  up  of  two  hemispherical 
masses,  the  two  new  cocci  resulting  from  fission  of  the  old  one.  Morpho- 
logically, the  streptococcus  of  erysipelas  and  the  streptococcus  pyogenes  are 
nearly  identical,  only  that  the  cocci  of  erysipelas  are  somewhat  larger,  while 
both  are  somewhat  smaller  than  the  staphylococci. 

CULTIVATION. 

This  microbe  can  be  readily  cultivated  in  bouillon  at  ordinary  room- 
temperature;  also  upon  gelatin,  agar-agar,  and  solidified  blood-serum.  Upon 
solid  nutrient  media  the  appearances  of  the  cultures  resemble  very  strongly 
those  of  streptococcus  pyogenes.  There  is  less  tendency,  however,  to  the 
formation  of  terraces,  the  margin  is  thicker  and  more  irregular  in  outline, 
and  the  appearance  of  the  growth  is  more  opaque  and  whiter.  Eosenbach 
mentions,  as  another  distinguishing  feature  between  the  two,  that  the  culture 


414 


PKINCIPLES    OF    SURGERY. 


of  the  streptococcus  of  erysipelas  represents  the  shape  of  a  fern,  while  the 
outlines  of  the  cultures  of  the  pus-streptococcus  describe  the  shape  of  an 
aeaeia-leaf.  The  culture  appears  as  a  very  delicate  grayish-white  film.  The 
growth  is  very  slow,  and  the  individual  colonies  remain  small.  The  strepto- 
coccus of  erysipelas  does  not  liquefy  gelatin.  The  microbe  of  erysipelas 
grows  equally  well  when  oxygen  is  excluded.  If  gelatin  is  inoculated  by 
puncturing  with  a  needle  charged  with  a  pure  culture,  microscopical  colonies 
can  be  seen  the  whole  length  of  the  track  of  the  needle  at  the  end  of  twenty- 
four  hours.    In  four  days  the  culture  has  reached  the  height  of  development. 


Fig.  155.— stab  Culture  of  Streptococcus  of  Erysipelas  in  Gelatin  at  Ordinary 
Temperature  of  Room.     Four  days  old.     Natural  size.     (Baumgarten.) 


and  colonies  the  size  of  a  grain  of  sand  to  that  of  a  pin's  head  occupy  the 
whole  length  of  the  needle-track. 

In  cultures  the  microbe  retains  its  pathogenic  qualities  for  about  four 
months. 

INOCULATIOiS^    EXPERIMENTS. 

Fehleisen  produced,  artificially,  typical  erysipelas  in  rabbits  by  inject- 
ing pure  cultures  under  the  skin  of  the  ear.  Koch  and  Gaffky  used  culture 
grown  upon  solidified  blood-serum  and  inoculated  9  rabbits.  In  8  of  these 
typical  erysipelas  developed,  the  attack  lasting  from  six  to  twelve  days. 

Krause  obtained  positive  results  by  inoculating  gray  mice.    In  all  cases 


INOCULATION    FOE    THERAPEUTIC    PUEPOSES.  415 

where  the  inoculation  proved  successful  the  erysipelatous  inflammation 
started  at  the  point  of  inoculation^  and  extended  rapidly,  always  following 
the  lymphatic  channels.  In  Krause's  experiments  the  animals  died  after 
three  or  four  days,  even  when  only  a  minute  quantity  of  the  culture  was  in- 
jected under  the  skin  of  the  hack.  Examination  of  the  infected  tissues  after 
death  showed  that  the  inflammation  folloAved  the  invasion  of  the  microbes, 
and  consequently  the  principal  pathological  changes  were  found  within  and 
in  the  immediate  vicinity  of  the  lymphatic  channels. 

INOCULATION    FOE   THERAPEUTIC    PUEPOSES. 

As  soon  as  it  was  demonstrated  experimentally  that  simple,  uncompli- 
cated erysipelas  is  a  disease  attended  by  but  little  danger  to  life,  the  sug- 
gestion was  near  that,  if  the  disease  could  be  artificially  produced  in  man 
by  inoculation  with  pure  cultures,  the  local  and  general  conditions  thus  pro- 
duced might  prove  useful  in  the  cure  or  amelioration  of  some  diseases  not 
amenable  to  operative  treatment  and  internal  medication.  Of  7  persons  the 
subjects  of  inoperable  malignant  tumors,  inoculated  by  Fehleisen  with  pure 
cultures,  6  developed  typical  erysipelas;  in  the  seventh  case  the  patient  had 
passed  through  an  attack  of  erysipelas  only  a  few  weeks  previously,  and  was, 
in  all  probability,  still  protected  against  a  new  attack.  This  patient  was  in- 
oculated a  second  time  with  a  negative  result.  In  other  instances  a  second 
inoculation  failed  after  a  successful  inoculation.  The  period  of  incubation 
was  fixed  at  from  fifteen  to  sixty-one  hours.  The  microbe  was  found  only 
in  the  lymphatic  vessels  and  connective-tissue  spaces,  and  when  the  culture 
was  pure  suppuration  was  never  produced.  Fehleisen  has  seen,  by  this  treat- 
ment, a  cancer  of  the  breast  become  smaller,  a  lupus  disappear  almost  com- 
pletely, while  a  case  of  fibrosarcoma  and  another  of  sarcoma  were  not  mate- 
rially affected  by  this  method  of  treatment.  Janicke  and  Neisser  have  re- 
corded a  death  from  erysipelas  thus  intentionally  produced  in  a  case  of 
cancer  of  the  breast  beyond  the  reach  of  an  operation.  At  the  necropsy  it 
was  proved  that  the  tumor  had  almost  completely  disappeared,  and  the  mi- 
croscopical examination  of  portions  that  had  remained  appeared  to  show,  that 
the  tumor-cells  had  been  destroyed  through  the  direct  action  of  the  microbes. 
Biedert  saw,  in  a  child  suffering  from  a  sarcoma  involving  the  posterior  part 
of  the  cavity  of  the  mouth  and  pharynx,  the  left  half  of  the  tongue,  the 
naso-pharyngeal  space,  and  the  right  orbit,  the  tumor  disappear  almost  com- 
pletely during  an  attack  of  erysipelas.  Cases,  on  the  other  hand,  have  been 
reported  in  which,  after  an  accidental  or  intentional  attack  of  erysipelas,  the 
tumor  commenced  to  grow  more  rapidly.  ISTeelsen  reports  a  case  of  car- 
cinoma of  the  breast,  in  which,  after  two  severe  attacks  of  erysipelas,  the 
tumor  not  only  commenced  to  grow  faster,  but  at  the  same  time  the  regional 
infection  progressed  also  more  rapidly. 


416  PEINCIPLES    OF    SUEGERY. 

Schwimmer  gives  an  account  of  11  cases  of  lupus  in  all  of  which  no 
improvement  was  observed  after  an  intercurrent  attack  of  erysipelas.  In  a 
case  of  keloid  an  attack  of  erysipelas  was  followed  by  marked  improvement, 
and  a  lipoma  underwent  a  similar  favorable  change  from  the  same  cause. 
Syphilitic  lesions  he  saw  temporarily  benefited,  while  the  erysipelas  had  no 
effect  in  permanently  influencing  the  course  of  the  disease. 

Bruns  gives  an  account  of  the  effect  of  erysipelas  on  tumors  in  22  pa- 
tients. Among  these,  3  cases  of  sarcoma  were  permanently  cured.  Two  cases 
of  multiple  keloid  after  burns  were  also  cured.  In  4  cases  of  lymphoma  of 
the  neck  some  of  the  glands  became  smaller  and  some  disappeared.  In  5 
cases  the  erysipelas  was  artificially  produced  by  inoculation  with  a  pure  cult- 
ure. In  3  cases  of  carcinoma  of  the  mamma  1  was  not  infiuenced  by  the 
disease,  1  became  one-half  smaller,  and  1  was  reduced  to  a  small  induration 
in  the  scar,  the  size  of  a  pea.  A  multiple  fibrosarcoma  was  greatly  bene- 
fited, while  an  orbital  sarcoma  was  not  improved. 

Coley  has  made  extensive  use  of  a  combined  sterile  culture  of  the  strep- 
tococcus of  erysipelas  and  the  bacillus  prodigiosus  in  the  treatment  of  in- 
operable malignant  tumors.  From  his  published  reports  it  appears  that  a 
number  of  cases  of  sarcoma  were  permanently  cured.  The  writer  has  given 
this  treatment  a  faithful  trial  in  more  than  fifty  cases  of  inoperable  malig- 
nant tumors  during  the  last  few  years,  with  uniform  negative  results.  In 
some  of  these  cases  the  reaction  was  so  intense  that  the  general  health  was 
much  impaired  by  the  treatment. 

In  view  of  the  uncertainty  of  the  result,  and  the  not  inconsiderable 
danger  which  attends  the  intentional  form  of  erysipelas  in  patients  debili- 
tated by  antecedent  disease,  it  is  safe  to  jDredict  that  no  further  inoculations 
will  be  made  in  man  until,  perhaps,  future  research  will  demonstrate  a  cer- 
tain specific  antagonistic  action  of  the  streptococcus  of  erysipelas  against 
some  other  pathogenic  microbes  the  cause  of  grave  diseases  not  amenable  to 
successful  treatment  by  less  heroic  measures. 

MANNER    OF    INFECTION. 

An  intact  skin  or  mucous  membrane  furnishes  absolute  protection 
against  infection  with  the  streptococcus  of  erysipelas.  This  microbe  cannot 
reach  the  lymphatic  vessels  without  an  infection-atrium,  which  may  be  a 
small  abrasion,  a  wound,  blister,  ulcer;  in  fact,  any  breach  of  continuity  in 
the  skin  or  mucous  membrane.  Before  antiseptic  surgery  was  practiced  in- 
fection frequently  occurred  through  accidental  or  intentional  wounds.  C. 
W.  Allen  says  that  in  50  per  cent,  the  entrance  of  infection  is  through  some 
skin  defect.  In  9  out  of  100  cases  the  disease  commenced  in  the  pharynx, 
in  3  it  was  due  to  a  nasal  catarrh,  and  in  1  a  lacrymal  fistula  served  as  an 
avenue  of  infection.     Antiseptic  surgery  has  greatly  diminished  the  fre- 


MANNER    OF    INFECTION.  417 

quency  of  traumatic  erysipelas,  but  has  not  completely  eradicated  it,  as  an 
occasional  case  will  occur  in  the  hands  of  the  most  careful  aseiDtic  surgeons. 
Even  before  the  mierobic  cause  of  erysipelas  was  known,  Trousseau,  one  of 
the  closest  of  clinical  observers,  claimed  that  infection  with  the  virus  of 
erysipelas  is  only  possible  through  some  wound  or  abrasion  of  the  skin;  the 
latter  may  be  so  insignificant  as  to  be  unnoticeable  and  entirely  overlooked 
by  both  patient  and  physician.  Idiopathic,  or  spontaneous,  erysipelas,  so 
called,  does  not  exist;  every  case  of  erysipelas  is  traumatic,  in  so  far  that 
by  injury  or  disease  the  necessary  infection-atrium  must  be  created  through 
which  the  streptococcus  can  reach  the  lymphatic  vessels.  In  erysipelas  with- 
out a  tangible  infection-atrium,  infection  occurs  through  a  minute  puncture 
or  abrasion,  which  may,  perhaps,  never  have  attracted  the  patient's  atten- 
tion, and  which  has  become  invisible  at  the  time  the  disease  is  first  noticed. 
Infection,  however,  may  also  take  place  through  a  mucous  membrane, 
through  which  the  microbes  enter  the  tissues  in  the  same  manner  and  under 
the  same  conditions  as  when  infection  takes  place  through  the  skin.  One 
of  the  severest  cases  of  erysipelas  that  ever  came  under  my  observation  com- 
menced in  the  pharynx,  or  tonsils,  and,  as  the  symptoms  subsided  here,  a 
typical  and  severe  facial  erysipelas  developed.  As  the  patient  was  suffering 
at  the  same  time  from  secondary  syphilis,  it  is  probable  that  the  streptococcus 
of  erysipelas  entered  the  tissues  through  the  secondary  syphilitic  lesions  in 
the  pharynx.  In  the  tissues  the  streptococcus  of  erysipelas  invades  the 
lymphatic  channels  exclusively,  and  manifests  here  its  specific  pathogenic 
qualities. 

The  erysipelatous  inflammation  is,  in  reality,  a  specific,  progressive 
lymphangitis,  the  paralymphatic  tissues  becoming  affected  by  contiguity. 
Within  the  lymphatic  channels  the  microbe  multiplies,  and  diffusion  of  the 
infection  takes  place  in  the  course  of  the  lymphatic  vessels,  but  does  not  al- 
ways follow  in  the  direction  of  the  lymph-stream.  The  lymphatic  vessels  are 
often  found  crowded  with  the  microbe,  which  is  destroyed  in  a  short  time, 
as  with  the  subsidence  of  the  inflammation  the  microbe  disappears.  Accord- 
ing to  Koch  and  Fehleisen,  the  microbe  is  always  found  most  numerous  in 
the  portion  of  the  skin  corresponding  to  the  border  of  the  inflamed  area.  At 
this  point  the  lymphatics  frequently  appear  completely  blocked  by  dense 
colonies  of  this  microbe,  so  that  no  lymph-corpuscles  can  be  seen  among 
them.  As  the  inflammation  extends  to  the  surrounding  connective  tissue, 
some  of  the  microbes  leave  the  lymphatics  and  enter  the  connective-tissue 
spaces,  where  they  come  in  contact  with  the  inflammatory  exudation.  Within 
the  lymphatic  vessels  the  streptococci  are  found  between  the  lymph  and  col- 
orless blood-corpuscles;  in  the  connective  tissue  they  are  found  also  within 
the  protoplasm  of  leucocytes. 

Metschnikoff  maintains,  in  opposition  to  most  of  the  modern  authors, 


418 


PKINCIPLES    OF    SURGEEY. 


that  the  arrest  of  the  extension  of  the  erysipehitous  inflammation  is  accom- 
plished by  phagocytosis.  The  accumulation  of  leucocytes  in  the  inflamed 
tissues  has^  imdoubtedly,  a  salutary  eft'ect  in  mechanically  blocking  the 
avenues  through  which  infection  takes  place;  but  as  most  of  the  microbes 
are  outside  of,  and  not  within,  the  leucocytes  and  lymph-corpuscles,  it  is  dif- 


Fig. 


156. — Section  through  Skin  near  the  Margin  of  the  Erysipelatous  Zone.    1,  1, 
a  lymphatic  vessel  filled  with  streptococci  in  chains.     X  700.     (Koch.) 


each 


ficult  to  conceive  how  limitation  of  the  extension  of  the  infection  could  be 
accomplished  solely  by  phagocytosis.  The  microbes  have  a  very  short  ex- 
istence in  the  tissues;  the  inflammation  which  they  initiate  continues  for 
some  time  after  all  microbes  have  disappeared.  The  toxins  which  the  mi- 
crobes secrete  produce  protoplasmic  alteration  of  the  connective-tissue  cells 
and  the  capillary  blood-vessels,  which  prolong  the  inflammation  beyond  the 
period  when  the  tissues  are  in  a  sterile  condition.    Others  have  claimed  that 


Fig.  157. — Section  of  Skin  in  Erysipelas,  v,  v,  section  of  two  lymphatic  vessels 
containing  white  corpuscles  and  chains  of  cocci;  m,  m,  chain  cocci;  t,  connective  tis- 
sue;   a,  connective  tissue  and  migrating  cells.     X  600.     {After  Coriiil  and  Babes.) 

self-limitation  of  erysipelas  is  due  to  destruction  of  the  microbes  by  the  high 
temperature  which  attends  the  disease.  De  Simone  has  recently  shown  that 
pure  cultures  of  the  streptococcus  of  erysipelas  lose  their  power  of  reproduc- 
tion if  they  are  exposed  for  two  days  consecutively  to  a  temperature  of  39.5° 
to  41°  C.    Clinical  experience,  however,  has  demonstrated  conclusively  that 


EELATION  OF  ERYSIPELAS  TO  PUEKPERAL  FEVER.         419 

erysipelas  is  not  arretted  in  its  course  by  a  temperature  of  40°  C.  or  more. 
It  appears  that  the  streptococcus  exhausts  the  soil  of  the  nutrient  material 
which  it  requires  for  its  growth  and  reproduction  in  a  short  time.  In  the 
blood-vessels  of  the  inflamed  skin  no  streptococci  can  be  found,  but  that  they 
occasionally  enter  the  blood-vessels  is  sufficiently  evident  from  the  occur- 
rence of  metastatic  erysipelas  and  the  direct  transmission  of  erysipelas 
from  mothet  to  foetus  by  infection  through  the  placental  circulation.  As 
the  streptococcus  of  erysipelas  produces  its  pathogenic  effects  in  the  lym- 
phatic vessels  and  diffuses  itself  through  these  channels  in  the  tissues,  it 
becomes  obvious  that  in  all  cases  infection  takes  place  as  soon  as  localiza- 
tion is  effected  in  the  superficial  lymphatic  structures,  or  in  the  spaces 
contributary  to  them  and  in  direct  connection  with  an  infection-atrium. 

RELATION"    OF   ERYSIPELAS    TO    PUERPERAL    FEVER. 

Obstetricians  recognized  the  danger  of  exposing  puerperal  women  to 
the  infection  which  might  emanate  from  erysipelatous  patients  long  before 
the  microbe  of  erysipelas  was  known.  Since  the  discovery  of  the  microbe 
by  Fehleisen,  this  subject  has  attracted  renewed  attention,  and  positive 
knowledge  has  accumulated  both  from  accurate  clinical  observation  and  from 
the  fertile  and  more  positive  field  of  experimentation.  Gusserow  asserted, 
upon  the  basis  of  an  extensive  experience,  that  no  direct  etiological  relations 
exist  between  the  contagium  of  erysipelas  and  puerperal  fever.  He  had 
under  his  care  puerperal  women  suffering  from  erysipelas  of  the  skin  with- 
out any  serious  disturbances  following  in  the  genital  tract.  In  10  other 
cases,  1  of  them  occurring  during  an  epidemic  of  puerperal  fever,  the  ery- 
sipelas was  observed  as  a  complication  of  septic  affections  of  the  genital  or- 
gans. Gusserow  claims  that  in  this  case  it  cannot  be  claimed  that  erysipe- 
las could  have  caused  the  puerperal  affection,  as  the  latter  preceded  the 
former.  But  another  point  could  be  raised,  as  it  might  be  claimed  that  the 
septic  processes  should  be  made  answerable  for  the  occurrence  of  erysipelas. 
This  author  has  studied  this  subject  also  by  way  of  experiment.  A  pure 
culture  of  the  streptococcus  erysipelatosus,  which  had  been  tested  and  found 
reliable  in  producing  erysipelas  by  the  usual  methods  of  inoculation,  was 
injected  into  the  peritoneal  cavity  of  2  rabbits;  in  2  others  it  was  applied  to 
an  open  wound  of  the  abdomen,  and  in  the  last  2  animals  it  Avas  injected  intO' 
the  subserous  conective  tissue  of  the  peritoneum.  In  all  of  these  animals 
no  effect  was  produced,  and  no  pathological  changes  were  detected  at  the 
point  of  injection  when  the  animals  were  killed,  some  time  after  the  in- 
oculation. Gusserow  looks  upon  the  results  of  these  experiments,  if  not  as 
positive  proof,  nevertheless  as  strong  evidence  against  the  claim  that  ery- 
sipelas can  cause  puerperal  sepsis.  Winckel,  an  equally  reliable  and  able 
observer,  has  come  to  entirely  opposite  conclusions.     He  cultivated  from  a 


420  PEINCIPLES    OF    SUEGEEY. 

parametritic  abscess,  wliich  had  developed  after  childbed,  Fehleisen's  strep- 
tococcus. Injections  of  this  culture  into  rabbits  produced  typical  erysipelas. 
The  same  author  also  observed  erysipelas  following  in  a  puerperal  woman 
suffering  from  suppurative  perimetritis,  pleuritis,  and  metrolymphangitis. 
The  patient  died  on  the  thirteenth  day.  The  starting-point  of  the  erysipelas 
could  be  traced  to  an  ulcer  of  the  vulva.  Blood  taken  from  the  right  side 
of  the  heart  soon  after  death  was  inoculated  upon  a  solid  nutrient  medium, 
and  produced  a  culture  of  the  streptococcus  of  erysipelas.  The  same  culture 
was  obtained  by  inoculations  with  fluids  taken  from  the  peritoneal  and 
pleural  cavities,  the  uterus,  kidneys,  and  the  liver.  In  3  cases  a  culture  thus 
obtained  was  injected  into  the  peritoneal  cavity  of  rabbits,  and  no  perito- 
nitis followed.  In  one  experiment  the  injection  produced  suppurative  peri- 
tonitis. Guinea-pigs  proved  less  susceptible  to  infection  than  rabbits.  In 
white  mice  the  inoculations  were  invariably  productive  of  a  fatal  disease. 
From  the  results  of  these  experiments  the  author  claims  that  the  virus  of 
erysipelas  is  one  of  the  most  virulent  puerperal  poisons,  and  believes  that 
they  prove  the  causal  relations  of  erysipelas  to  puerperal  sepsis. 

Doyen  also  found,  both  in  mild  and  severe  cases  of  puerperal  fever,  a 
streptococcus  similar  to  the  one  described  by  Eosenbach  and  Fehleisen.  He 
made  some  inoculations  to  determine  the  relationship  between  puerperal 
sepsis  and  erysipelas.  The  streptococcus  found  in  the  infected  tissues  of 
puerperal-fever  patients  caused  erysipelas,  and  the  streptococcus  found  in 
erysipelas  developed  puerperal  fever.  From  his  own  observations  and  ex- 
periments the  author  arrived  at  the  conclusion  that  the  microbe  of  puerperal 
sepsis  is  the  same  as  that  of  erysipelas.  From  a  clinical  and  bacteriological 
;stand-point  it  is  evident  that  puerperal  sepsis  from  infection  with  the  strep- 
iococcus  of  erysipelas  can  only  occur  when  the  streptococcus  is  brought  in 
'Contact  with  an  absorbing  surface  in  the  genital  tract;  but  when  this  takes 
place,  and  the  microbes  reach  the  enlarged  lymphatic  vessels  of  the  puer- 
peral uterus,  the  most  violent  and  fatal  form  of  puerperal  sepsis  is  almost 
certain  to  follow. 

EELATION    OE   EETSIPELAS   TO    PHLEGMONOUS    INFLAMMATION"    AND 

SUPPUEATION. 

Some  difference  of  ojoinion  still  exists,  among  bacteriologists,  with  re- 
gard to  the  question  whether  the  streptococcus  of  erysipelas  possesses  py- 
ogenic properties.  The  majority  of  those  who  have  studied  this  subject  ex- 
perimentally do  not  consider  the  streptococcus  of  erysipelas  as  a  pus-mi- 
crobe, and  assert  that  when  suppuration  takes  place  in  erysipelas  it  is  the 
result  of  a  secondary  infection  with  pus-microbes,  and,  on  this  account,  look 
upon  phlegmonous  inflammation  as  a  complication,  and  not  as  a  condition 
belonging  to  the  erysipelatous  process.    Hajeck  made  careful  investigations 


EELATION    TO    PHLEGMONOUS    INFLAMMATION   AND    SUPPUEATION.     421 

to  show  that  the  streptococcus  of  erysipelas  is  neither  in  form  nor  culture 
materially  different  from  the  streptococcus  pyogenes,  but  he  showed,  also, 
that  in  51  cutaneous  or  subcutaneous  inoculations  with  a  pure  culture  of  the 
streptococcus  of  erysipelas  in  rabbits  the  result  was  always  a  superficial  mi- 
grating dermatitis  which  resembled  to  perfection  erysipelas  in  man,  while 
similar  injections  with  the  streptococcus  of  pus  produced  a  more  intense 
and  deeply-seated  inflammation,  which  in  almost  every  instance  terminated 
in  suppuration.  The  difference  in  the  action  of  the  two  microbes  on  the 
tissues  plainly  demonstrated  their  non-identity.  Microscopical  examination 
of  the  inflamed  tissue  showed  a  still  more  important  difference  as  far  as  the 
localization  and  local  diffusion  of  the  microbes  were  concerned.  The  mi- 
crobe of  erysipelas  was  always  found  with  the  products  of  inflammation 
within  the  lymphatic  vessels,  and  only  exceptionally  in  the  connective-tissue 
spaces,  which  anatomically  are  only  a  part  of  the  lymphatic  system.  The 
pus  streptococcus  penetrates  the  tissues  more  deeply;  it  is  not  only  found 
in  the  lymphatic  vessels  and  connective-tissue  spaces,  lut  it  migrates  beyond 
the  lymphatic  channels  and  infects  different  hinds  of  tissue,  thus  giving  rise 
to  a  more  deeply  seated  and  more  intense  inflammation.  The  streptococcus 
of  erysipelas  is  found  only  exceptionally  in  the  immediate  vicinity  of  blood- 
vessels, while  the  microbe  'of  pus  can  alivays  be  see\m  arranged  in  radiate  lines 
around  vessels  entering  the  adventitia,  the  muscular  coat,  and  often  even  the 
lumen  of  the  vessel.  In  man  the  same  histological  differences  can  be  seen 
in  the  tissues  the  seat  of  erysipelatous  and  phlegmonous  inflammation  as  in 
the  artiflcial  conditions  in  animals  subjected  to  experiment,  and  the  same 
pathological  differences  are  also  constantly  found.  The  author  asserts  that 
Fehleisen  was  in  error  when  he  claimed  that  the  formation  of  abscesses  oc- 
curred independently  of  the  erysipelatous  infection.  He  affirms  that,  in 
rabbits  inoculated  with  the  virus  of  erysipelas,  after  the  acute  inflammation 
has  subsided  circumscribed  small  nodules  which  remain  may  suppurate,  but 
suppuration  never  becomes  diffuse;  while  after  injection  with  cultures  of 
the  streptococcus  pyogenes  the  inflammation  assumes  a  phlegmonous  type 
and  the  suppuration  is  always  more  diffuse.  Hajeck  maintains  that  under 
certain  circumstances  a  circumscribed  superficial  suppuration  can  also  take 
place  in  erysipelatous  inflammation  in  man.  When  suppuration  in  a  joint 
takes  place,  however,  it  is  not  caused  by  the  erysipelatous  infection,  but  is 
due  to  the  presence  of  pus-microbes.  Eiselsberg,  Bonome,  Bordini,  Passet, 
and  Simone  are  of  the  opinion  that  the  streptococcus  of  erysipelas  and  the 
streptococcus  of  suppuration  do  not  differ  in  their  pathogenic  effects. 

Smirnoff  found  in  one  case  of  erysipelas  the  specific  microbe  in  the 
metacarpo-phalangeal  joint  of  the  left  hand,  which  was  the  seat  of  the  dis- 
ease. In  the  case  of  a  man  who  had  died  of  erysipelas,  enormous  colonies  of 
the  streptococcus  were  found  in  the  right  shoulder-  and  knee-  joints.     The 


422  PKINCIPLES    OF    SUKGEKY. 

synovial  fluid  injected  into  rabbits  occasioned  erysipelas  migrans.  Accord- 
ing to  the  recent  researches  of  von  Lingelsheim,  the  streptococcus  pyogenes 
differs  from  the  streptococcus  erysipelatosus  in  being  pathogenic  both  for 
mice  and  rabbits,  while  the  latter  is  pathogenic  for  rabbits  only. 

Eheiner  found  Fehleisen's  streptococcus  in  all  cases  of  traumatic  ery- 
sipelas which  he  examined,  but  was  unable  to  find  it  in  2  cases  of  gangrenous 
erysipelas  following  typhus.  In  these  cases  he  found  bacilli  which  he  be- 
lieved were  identical  with  Klebs-Eberth's  bacillus  of  typhus.  At  the  pres- 
ent time  the  opinion  of  the  identity  of  the  microbes  of  pus  and  erysipelas  is 
again  gaining  ground.  Schonfeld  found  the  same  coccus  in  the  lungs  and 
especially  in  the  dilated  lymphatics  of  this  organ  in  a  patient  who  died  from 
the  effects  of  an  attack  of  erysipelas  complicated  by  fibrinous  pneumonia. 
Mosny  obtained  a  pure  culture  of  the  streptococcus  of  erysipelas  from  the 
inflamed  lung  of  a  servant  who  attended  his  master  during  an  attack  of 
facial  erysipelas  and  who  died  the  second  day  after  an  attack  of  pneumonia. 
Jordan,  who  is  a  firm  believer  in  the  non-specific  nature  of  the  microbe  of 
erysipelas^  made  a  careful  clinical  and  bacteriological  study  of  2  cases  of 
erysipelas  in  the  clinic  at  Heidelberg.  In  "the  first  case  the  disease  started 
as  a  typical  facial  erysipelas  and  which  was  attended  by  phlegmonous  in- 
flammation of  the  forehead  and  adipose  tissue  of  the  orbital  regions,  and  was 
soon  followed  in  rapid  succession  by  metastatic  periostitis  of  right  fibula, 
erysipelas  of  skin  of  leg,  migrating  pneumonia  of  both  lungs,  dilatation  of 
hearty  recurring  erysipelas  of  face.  The  patient  finally  recovered.  From 
all  of  the  lesions,  local  and  distant,  he  cultivated  the  staphylococcus  pyog- 
enes aureus.  The  nurse  who  attended  this  patient  was  taken  with  facial 
erysipelas  on  the  third  day,  and  from  the  serum  obtained  from  a  puncture 
near  the  erysipelatous  zone  he  cultivated  the  same  microbe. 

Kahlden,  after  a  careful  study  of  the  recent  literature  on  erysipelas 
and  the  difference  in  opinion  on  the  pathogenic  properties  of  the  strepto- 
coccus erysipelatosus,  remarks  that  the  subtility  in  the  differences  between 
the  morphology  and  the  cultures  of  the  microbes  of  erysipelas  and  the  strep- 
tococcus of  suppuration  is  undoubtedly  the  reason  why  no  uniformity  of 
opinion  exists  in  regard  to  their  specific  pathogenic  effects,  especially  as  to 
the  possibility  of  Fehleisen's  streptococcus  producing  suppuration.  To  this 
I  might  add  that  not  every  superficial  diffuse  inflammation  of  the  skin  is 
erysipelas,  and  not  every  abscess  occurring  during,  or  soon  after,  an  attack 
of  erysipelas  should  be  considered  as  a  product  of  the  erysipelatous  infection. 
The  surgeon  will  do  well  to  adhere  to  the  teachings  of  Fehleisen,  who  is 
positive  in  his  assertion  that  the  streptoooccus  of  erysipelas  never  produces 
suppuration,  until  more  convincing  proof  shall  have  been  furnished  of  the 
pathogenic  identity  of  the  streptococcus  of  erysipelas  and  the  streptococcus 
of  suppuration. 


SYMPTOMS   AND    DIAGNOSIS.  433 


SYMPTOMS    AND    DIAGNOSIS. 


Erysipelas,  like  most  of  the  acute  infectious  diseases,  has  no  well- 
marked  premonitory  stage,  the  attack  being  sudden  and  followed  by  all  the 
symptoms  which  usher  in  an  acute  febrile  affection.  The  period  of  incuba- 
tion in  man  has  been  fixed  at  from  fifteen  to  sixty-one  hours  by  the  inocula- 
tions which  have  been  made  to  produce  the  disease  artificially  for  therapeu- 
tic purposes.  Inoculations  prove  successful  if  the  skin  is  punctured  with  a 
needle  the  point  of  which  had  been  dipped  into  a  pure  culture  of  the  strep- 
tococcus. Such  punctures  have  no  visible  lesion  after  a  few  hours:  a  fact 
which  readily  explains  the  disappearance  of  a  visible  infection-atrium  at  the 
time  the  disease  appears,  in  cases  of  erysipelas  developing  without  a  demon- 
strable breach  of  continuity  in  the  skin.  Eoger  records  597  personal  ob- 
servations of  erysipelas.  Of  this  number,  he  was  able  to  calculate  with  pre- 
cision the  time  of  incubation  in  41  cases.  In  5  cases  it  was  less  than  18 
hours;  in  5  more  it  ranged  from  18  to  24  hours;  the  longest  period  was 
1  case  in  which  it  occupied  23  days.  However,  in  this  case  he  admits  the 
possibility  of  a  later  infection. 

In  the  adult  the  disease  commences,  almost  without  exception,  with 
a  chill  which  sometimes  amounts  to  a  severe  rigor.  Nausea  and  vomiting 
are  often  present  during  the  first  few  hours.  The  chill  is  followed  by  a 
rise  in  the  temperature,  which  in  a  few  hours  increases  to  104°  F.  or  more. 
The  fever  assumes  a  continuous  type,  and  in  uncomplicated  cases  the  dif- 
ference between  the  morning  and  evening  temperature  is  slight.  Headache, 
thirst,  and  complete  loss  of  appetite  are  constant  and  prominent  symptoms. 
The  pulse  is  at  first  full  and  bounding  and  seldom  exceeds  100  beats  per 
minute.  In  severe  cases  delirium  is  present  almost  from  the  beginning,  and 
continues  until  the  fever  subsides.  Almost  simultaneously  with  the  appear- 
ance of  the  general  symptoms,  the  skin  in  the  immediate  vicinity  of  the 
infection-atrium  shows  evidences  of  the  existence  of  a  superficial  inflam- 
mation. The  patient  complains  of  a  sense  of  tightness  in  the  part,  which  is 
accompanied  by  a  burning  and  itching  sensation. 

In  traumatic  erysipelas  the  wound  presents  no  changes  in  its  appear- 
ance; if  suppuration  is  present  the  purulent  discharge  becomes  somewhat 
diminished  in  quantity  and  the  pus  is  rendered  more  serous.  The  skin 
around  the  seat  of  infection  is  firmer  to  the  touch,  and,  if  the  erysipelas  has 
started  from  a  wound,  infection  has  occurred  from  a  certain  portion  of  the 
wound,  while  the  remainder  shows  no  evidences  which  point  to  erysipelatous 
infiammation.  The  skin  which  is  involved  by  the  erysipelatous  inflammation 
presents,  almost  from  the  beginning,  a  characteristic  rose  or  crimson  color. 
With  the  appearance  of  the  typical  discoloration  the  inflammatory  exuda- 
tion has  reached  its  height.    The  color  disappears  under  pressure,  but  upon 


424  PRINCIPLES    OF    SUEGEEY. 

the  removal  of  the  pressure  no  dej)ression  is  left,  showing  that  little  or  no 
oedema  is  present.  The  induration  of  the  skin  is  most  marked  at  the  border 
of  the  erysipelatous  zone,  and  disappears  with  the  absorption  of  the  inflam- 
matory product  and  the  return  of  the  natural  color  of  the  skin.  The  mar- 
gin of  the  zone  is  abrupt  and  distinct  on  the  side  of  the  healthy  skin.  The 
border  of  the  erysipelatous  zone  is  not  straight,  but  irregular,  and  often 
fan-like  projections  can  he  seen  and  felt  which  project  into  the  healthy  sJcin, 
and,  when  present,  they  are  characteristic,  almost  pathognom^onic,  of  this  form 
of  dermatitis.  The  degree  of  swelling  varies  according  to  the  intensity  of  the 
infection  and  the  anatomical  structure  of  the  part  involved. 

If  the  infection  is  intense  and  parts  are  implicated  which  are  abun- 
dantly supplied  with  loose  connective  tissue,  the  swelling  is  greater  than  in 
cases  where  the  infection  is  mild  or  the  skin  is  stretched  over  firm,  resisting . 
parts.  In  facial  erysipelas,  for  instance,  the  swelling  is  much  greater  around 
the  orbits  than  in  the  scalp,  because  in  the  former  locality  the  loose,  cellu- 
lar, connective  tissue  underneath  the  skin  becomes  swollen  and  oedematous 
from  the  escape  into  it  of  the  inflammatory  transudation. 

The  specific  inflammation,  starting  from  the  point  of  infection,  spreads 
continuously  and  uninterruptedly  along  the  course  of  the  superficial  lym- 
phatics, but  is  not  limited  to  the  direction  of  the  lymph-current.  The  intra- 
lymphatic  diffusion  of  the  streptococcus  is  not  a  passive,  but  an  active,  proc- 
ess. As  this  microbe  is  non-motile,  its  transportation  in  a  direction  opposite 
to  the  lymph-stream  can  only  occur  by  its  reproduction.  The  lymph-current 
in  most,  if  not  all,  'of  the  inflamed  lymphatic  vessels  is  temporarily  arrested  hy 
the  Hocking  of  the  interior  of  the  lymphatic  vessels  with  colonies  'of  the  strepto- 
coccus and  the  accumulation  of  lymph-corpuscles;  consequently  the  colonies 
become  fixed  points  from  which  new  tissues  are  infected  hy  their  increase  in 
size  in  all  directions,  muing  to  rapid  reproduction  of  the  microbe.  The  fever 
continues  until  the  infection  comes  to  a  stand-still.  The  intensity  of  the 
subjective  symptoms  does  not  always  correspond  with  the  temperature,  as 
patients  may  feel  quite  well  when  the  temperature  registers  104°  to  105° 
F.,  while  others  show  evidences  of  a  serious  disturbance  with  a  much  lower 
temperature.  I^arge  bullae  usually  result  from  confluence  of  a  number  of 
vesicles.  The  contents  of  these  blisters  are  first  serous,  but  suppuration  may 
follow  later  from  the  entrance  of  j)us-microbes.  Bullffi  with  hgemorrhagic 
contents  denote  a  grave  attack. 

The  duration  of  erysipelas  is  extremely  variable.  Genuine  erysipelas 
may  run  a  typical  course  and  terminate  in  recovery  in  two  days,  or  the  dis- 
ease may  extend  over  a  period  of  two  weeks  or  more.  The  extent  of  surface 
successively  invaded  determines  its  duration.  If  it  start  from  a  wound  of 
the  hand  it  may  extend  along  the  forearm  and  arm  to  the  shoulder,  from 
here  along  the  back  to  one  or  both  of  the  lower  extremities,  and  before  such 


CLINICAL    FOEMS    OF    EKYSIPELAS.  425 

a  large  territory  of  skin  lias  passed  through  all  the  stages  of  the  disease  more 
than  four  weeks  may  elapse.  As  soon  as  the  disease  ceases  to  migrate  the 
general  symptoms  subside,  and  within  a  few  days  the  skin  returns  to  its  nor- 
mal condition  and  the  patient  recovers  his  u^sual  health  in  a  remarkably 
short  time:  a  fact  which  tends  to  prove  that  erysipelas,  in  its  uncomplicated 
form,  does  not  impair  the  function  of  any  of  the  internal  organs  to  any 
considerable  extent.  Exfoliation  of  the  skin  is  a  usual  occurrence.  In  the 
differential  diagnosis  we  have  to  consider  lymphangitis,  erythema,  phleg- 
monous inflammation,  and  thrombophlebitis.  In  lymphangitis  from  other 
causes  than  the  streptococcus  of  erysipelas  the  inflammation  follows  larger 
lymphatic  channels,  which  appear  as  red  lines,  and  seldom,  if  ever,  is  the 
skin  proper  involved  in  the  inflammatory  process,  while  erysipelas  is  a  com- 
bination of  lymphangitis  with  dermatitis.  Erythema  appears  as  circum- 
scribed points  of  inflammation  in  the  skin  with  healthy  tissue  between, 
while,  on  the  other  hand,  erysipelas  shows  no  such  interruptions,  the  inflam- 
mation being  a  continuous,  uninterrupted  process  followed  by  speedy  repair. 
Phlegmonous  inflammation  is  accompanied  by  inflammation  of  the  skin, 
which  in  its  externat  appearances  closely  resembles  erysipelas;  but  the  dif- 
ferential diagnosis  rests  on  the  location  of  the  primary  inflammation,  which 
is  always  the  superficial  lymphatics  of  the  skin  in  erysipelas  and  the  sub- 
cutaneous tissue  in  phlegmonous  inflammation.  In  phlegmonous  inflam- 
mation there  is  no  abrupt  border  of  the  redness  of  the  skin  as  in  erysipelas. 
The  redness  of  the  skin  in  the  former  affection  gradually  shades  into  the 
usual  color  of  the  skin.  In  phlegmonous  inflammation  the  deep-seated  in- 
flammatory exudation  is  the  primary  pathological  condition,  and  the  lym- 
phangitis follows  as  a  secondary  result,  while  in  erysipelas  the  primary  spe- 
cific lymphangitis  and  dermatitis  are  primary  conditions;  and  if  the  subcu- 
taneous tissue  become  involved  later  on  it  must  be  regarded  as  a  complica- 
tion, and  not  as  an  integral  part  of  the  disease.  Patients  suffering  from 
erysipelas  complain  of  a  smarting,  burning,  or  itching  sensation  in  the  af- 
fected skin;  phlegmonous  inflammation  is  attended  by  severe  pain,  which  is 
of  a  throbbing  character.  Thrombophlebitis,  starting  from  a  chronic  ulcer 
of  the  leg,  has  often  been  mistaken  for  erysipelas,  not  only  by  laymen,  but 
also  by  physicians.  Thrombophlebitis  is  often  attended  by  inflammation  of 
the  tissues  around  the  inflamed  vein  and  of  the  superimposed  skin  (peri- 
phlebitis), but  the  inflammation  follows  in  the  course  of  the  vein,  and  not 
in  the  course  of  lymphatics;  at  the  same  time  the  vein  can  be  felt  as  a  solid, 
tender  cord. 

CLINICAL    FOEMS    OF    EEYSIPELAS. 

The  clinical  forms  of  erysipelas  are  identical  in  so  far  that  they  are  all 
caused  by  the  same  microbe,  and  that  the  disease  primarily  consists  of  a 


436  PRINCIPLES    OF    SURGERY. 

specific  lymphangitis  and  dermatitis;  but  they  vary  greatly,  according  to  the 
location  and  structure  of  the  part  affected,  the  intensity  of  the  infection, 
and  the  existence  of  complications. 

Erysipelas  Erythematosum. — This  is  the  mildest  form  of  erysipelas.  It 
is  described  as  erythematic  because  the  affected  skin  shows  but  little  swell- 
ing, and  the  affection  appears  more  as  an  efflorescence  than  an  inflammation. 
ISTo  bullae  form,  and  only  slight  exfoliation  takes  place  during  convalescence. 

Erysipelas  Bullosum. — In  this  form  the  inflammation  of  the  skin  is 
more  intense  and  the  swelling  more  marked,  in  consequence  of  which  blisters 
or  bullge  form  imderneath  the  cuticle.  The  pathological  condition  resem- 
bles a  burn  in  the  second  degree.  Eemoval  of  the  cuticle  leaves  the  papil- 
lary layer  of  the  skin  exposed.  The  bullse  often  become  the  seat  of  second- 
ary infection  with  pus-microbes,  which  transform  the  serous  contents  into 
pus.  From  such  superficial  foci  of  suppurative  inflammation  may  develop 
what  has  been  termed 

PhlegmonoTis  Erysipelas. — As  we  are  not  in  possession  of  conclusive 
proof  that  the  strej)tococcus  of  erysipelas  possesses  pyogenic  properties,  we 
can  only  explain  the  occurrence  of  phlegmonous  inflammation  of  the  tissues 
underneath  the  skin  affected  by  erysipelatous  inflammation  by  taking  it  for 
granted  that  the  deep-seated  phlegmonous  inflammation  is  caused  not  only 
by  the  streptococcus  of  erysipelas,  but  by  the  accidental  entrance  into  the 
tissues  of  microbes  of  suppuration.  As  soon  as  secondary  infection  with 
pus-microbes  takes  place  the  clinical  picture  of  erysipelas  is  overshadowed 
or  obscured  by  the  suppurative  inflammation.  The  typical  general  and  local 
symptoms  which  characterize  the  erysipelatous  inflammation  give  way  to 
symptoms  which  indicate  the  existence  of  a  diffuse  suppurative  inflamma- 
tion. The  temperature  shows  greater  remissions,  and  the  pulse  becomes 
more  rapid  and  feeble.  The  tongue  is  often  red  and  dry,  while  all  of  the 
remaining  symptoms  point  to  intoxication  from  absorption  of  toxins  pro- 
duced in  the  tissues  by  the  pus-microbes.  The  swelling  of  the  part  affected 
is  no  longer  limited  to  exudation  into  the  substance  of  the  skin,  but  affects 
mainly  the  deep-seated  tissues. 

We  have  reason  to  believe  that  in  most,  if  not  in  all,  cases  of  phleg- 
monous erysipelas  the  secondary  infection  with  pus-microbes  takes  place 
from  a  superficial  suppurating  focus  as  from  a  suppurating  bulla,  and  that 
the  microbes  from  here  invade  the  subcutaneous  connective  tissue.  The 
phlegmonous  inflammation  spreads  with  great  rapidity,  so  that  in  a  few 
days  the  skin  of  an  entire  extremity  may  become  undermined  with  pus,  the 
patient,  in  the  meantime,  having  complained  but  little  of  pain.  Such  an  ex- 
tremity on  palpation  imparts  the  sensation  of  a  partially  filled  diffuse  ab- 
scess-cavity. The  external  appearances  furnish,  often,  no  reliable  indica- 
tions of  the  extent  of  the  deep-seated  destruction.    If  incisions  are  made  at 


CLINICAL    FORMS    OF    ERYSIPELAS.  427 

tliis  time  a  large  quantity  of  pus  escapes,  mixed  with  slireds  of  necrosed  con- 
nective tissue,  and  examination  reveals  extensive  destruction  of  the  subcu- 
taneous connective  tissue  and  intermuscular  septa.  Phlegmonous  inflam- 
mation, as  a  rule,  does  not  attack  tissues  the  seat  of  an  erysipelatous  inflam- 
mation, but  the  tissues  weakened  by  this  disease  and  infected  with  pus-mi- 
crobes. A  sudden  increase  in  the  temperature  of  patients  suffering  from 
erysipelas  is  often  the  first  symptom  which  announces  this  complication,,  and 
such  an  occurrence  should  admonish  the  attendant  to  detect  it  early  in  order 
to  subject  it  to  timely  and  efficient  treatment. 

Erysipelas  Gangrsenosum. — This  is  an  exceedingly  grave  form  of  ery- 
sipelas. Most  of  the  authors  are  of  the  ojoinion  that  if  the  streptococcus  of 
erysipelas  multiplies  with  sufficient  rapidity,  in  the  interior  of  the  lym- 
phatic vessels  and  the  connective-tissue  spaces,  so  as  to  completely  block 
these  channels  by  its  growth,  a  sufficient  amount  of  toxins  is  produced  to 
cause  necrosis  of  the  tissues,  and  under  such  circumstances  the  erysipela- 
tous inflammation  terminates  in  gangrene  of  the  skin.  This  gangrene  may 
take  in  circumscribed  multiple  patches,  so  that  after  separation  and  elimi- 
nation of  the  dead  tissue  the  skin  present  a  cribriform  appearance  or  it 
may  involve  a  large  district  of  the  skin,  and  then  give  rise  to  extensive  loss 
of  this  structure  in  case  the  patient  survives  the  disease.  As  the  gangrene 
often  commences  in  the  portion  of  skin  covered  by  bullae,  it  still  remains  an 
open  question  whether  it  results  from  the  action  of  the  streptococcus  of 
erysipelas  or  whether  it  is  the  result  of  a  secondary  infection  with  pus- 
microbes.  Isolated  patches  of  gangrene  of  the  skin  are  met  with  in  many 
cases  that  terminate  in  recovery,  but  extensive  gangrene  of  the  skin  is  al- 
ways a  serious  complication,  as  it  may  result  in  death  from  septicgemia,  or, 
if  life  is  not  destroyed,  it  at  least  greatly  protracts  the  recovery,  and  often 
calls  for  a  tedious  treatment  to  restore  the  lost  tissue  by  skin-grafting. 

Erysipelas  Metastaticum. — By  metastatic  erysipelas  is  meant  the  oc- 
currence of  an  erysipelatous  inflammation  in  an  organ  or  a  part  where  the 
process  developed  separately  from  the  primary  field  of  infection.  If,  for 
instance,  erysipelas  should  appear  in  an  extremity  opposite  to  the  one  pri- 
marily affected,  without  extension  of  the  disease  across  the  skin  of  the  trunk, 
it  would  furnish  a  good  example  of  what  is  meant  by  metastatic  erysipelas. 
Again,  if,  during  an  attack  of  erysipelas  of  one  of  the  extremities,  the  patient 
should  be  attacked  with  symptoms  of  meningitis,  and  at  the  necropsy  the 
streptococcus  of  erysipelas  could  be  demonstrated  in  the  inflamed  envelopes 
of  the  brain,  this  would  furnish  another  illustration  of  metastatic  erysipelas. 
Two  possibilities  present  themselves  in  explaining  the  occurrence  of  meta- 
static erysipelas.  In  the  first  place,  colonies  of  the  streptococcus  in  an  active 
condition  might  reach  a  part  distant  from  the  erysipelatous  inflammation 
with  the  lymph-current,  and,  meeting  with  favorable  conditions,  might  es- 


428  PEINCIPLES    OF    SURGEEY. 

tablish.  an  additional  focus  of  erysipelatous  inflammation^  wliicli^  of  course, 
would  have  to  be  necessarily  in  a  part  between  the  primary  field  of  infection 
and  the  termination  of  the  lymphatic  vessels  leading  from  the  infected  dis- 
trict. If  no  such  connection  can  be  established,  then  the  metastatic  process 
results  from  the  entrance  of  streptococci  in  an  active  condition  into  the  cir- 
culation and  their  localization  in  distant  parts  or  organs  by  mural  implanta- 
tion upon  the  walls  of  capillary  vessels  prepared  for  their  localization  and 
reproduction.  In  most  instances  metastatic  erysipelas  is  of  such  an  embolic 
origin. 

The  occurrence  of  metastatic  erysipelas  of  the  skin  or  exposed  mucous 
membrane  could  also  be  satisfactorily  accounted  for  by  the  microbes  enter- 
ing the  tissues  from  without  through  a  new  and  distant  point  of  entrance, 
and  in  such  a  case  it  would  not  be  in  the  form  of  a  metastasis,  but  the  result 
of  a  new  inoculation  in  a  different  part  of  the  body. 

Erysipelas  Migrans. — Migration  of  the  inflammatory  process  is  one  of 
the  characteristic  clinical  features  of  erysipelas.  In  ordinary  cases  migration 
is  limited  to  the  anatomical  region  affected.  In  cases  of  facial  erysipelas 
the  disease  seldom  spreads  beyond  the  scalp,  and  in  erysipelas  of  the  extremi- 
ties the  disease  usually  subsides  after  it  has  extended  over  an  extremity. 
Migrating  erysipelas  is  that  form  of  the  disease  where  the  erysipelatous  in- 
flammation extends  from  place  to  place,  and  from  limb  to  limb.  I  have 
seen  this  form  most  frequently  in  infants,  starting  from  the  umbilicus  or 
the  external  genital  organs.  I  have  seen  it  start  from  these  points,  ascend 
in  an  upward  direction  along  the  anterior  aspect  of  the  body,  and,  after 
reaching  both  shoulders,  spread  to  the  upper  extremities,  later  to  descend 
down  the  back,  and  finally  terminate  in  the  toes,  after  traveling  nearly  over 
the  whole  surface  of  the  body.  Erysipelas  of  the  extremities  or  trunk  never 
extends  to  the  face  or  scalp,  while,  in  exceptional  cases,  erysipelas  of  the 
face  assumes  the  migrating  form.  Migrating  erysipelas  is  usually  attended 
by  only  moderate  swelling  and  slight  constitutional  disturbances.  One 
peculiarity  of  this  form  of  erysipelas  is  that  the  same  regions  may  become 
involved  a  second  time. 

Erysipelas  Facialis. — This  is  the  so-called  spontaneous  or  idiopathic 
form  of  erysipelas,  as  in  most  cases  even  close  inspection  does  not  reveal  the 
existence  of  an  infection-atrium.  The  disease  usually  commences  in  one 
of  the  alffi,  or  at  the  root  of  the  nose:  localities  where  minute  skin  lesions 
are  frequently  produced,  and  localities  which,  more  than  any  other  part  of 
the  face,  are  exposed  to  infection  by  contact.  As  far  as  its  extension  is  con- 
cerned, facial  erysipelas  pursues  the  most  typical  course.  The  inflammation 
spreads  toward  the  cheek  and  orbit  on  the  side  first  affected,  and  then  creeps 
across  the  bridge  of  the  nose  to  the  opposite  side,  to  follow  a  similar  course 
here.    About  the  second  or  third  day  it  reaches  the  forehead,  and  from  here 


PKOGNOSIS.  429 

and  the  outer  margins  of  the  orbits  it  invades  the  scalp,  to  terminate,  usu- 
all}^  about  the  end  of  a  week,  at  the  nape  of  the  neck.  The  chin  and  ante- 
rior aspect  of  the  neck  never  become  affected  in  facial  erysipelas.  Facial 
erj^sipelas  is  attended  by  considerable  swelling,  the  eyes  being  often  com- 
pletely closed  by  the  oedematous  lids.  Bullae  form  frequently  about  the  cen- 
tre of  the  cheeks  and  the  forehead.  One  of  the  dangers  of  facial  erysipelas 
consists  in  the  direct  extension  of  the  erysipelatous  inflammation  from  the 
skin  along  the  blood-vessels  to  the  meninges  of  the  brain.  The  meningitis 
under  these  circumstances  is  not  a  metastatic  process,  but  the  result  of  a 
direct  extension  of  the  inflammation  from  the  skin  to  the  meninges,  along 
structures  which  connect  them  through  the  intervening  skull.  Patients  who 
have  suffered  from  facial  erysipelas  are  not  protected  against  subsequent  at- 
tacks; in  fact,  experience  has  shown  that  they  are  more  prone  to  infection 
in  the  future  than  persons  who  have  never  suffered  from  this  disease.  If 
the  bullge  suppurate,  there  is  always  danger  arising  from  suppurative  throm- 
bophlebitis, suppurative  leptomeningitis,  and  supjDurative  encephalitis:  fatal 
complications  plainly  attributable  to  secondary  infection  with  pus-microbes. 
Traumatic  Erysipelas. — We  have  seen  that,  in  the  strict  sense  of  the 
word,  all  cases  of  erysipelas  are  traumatic  in  their  origin,  in  so  far  that 
infection  never  takes  place  through  the  intact  skin  or  a  mucous  membrane; 
consequently,  the  disease  never  occurs  without  an  infection-atrium,  which 
may  be  a  wound  or  a  lesion  of  the  surface  through  which  the  streptococcus 
gains  entrance  into  the  lymphatic  channels.  The  expression  "traumatic  ery- 
sipelas" is  still  retained  for  the  purpose  of  designating  erysipelas  as  one  of 
the  numerous  forms  of  Avound  complications.  If  a  recent  wound  is  infected 
with  the  microbes  of  erysipelas  the  disease  develops  within  fifteen  to  sixty- 
one  hours  after  the  accident  or  operation.  The  disease  may  occur  in  conse- 
quence of  later  infection  at  any  time  before  cicatrization  is  completed,  as 
granulations  furnish  no  absolute  protection  against  infection.  I  have  seen 
the  disease  originate  more  frequently  in  granulating  than  in  recent  wounds: 
a  strong  argument  in  support  of  the  advice  that  full  aseptic  precautions 
should  not  he  relinquished  until  the  healing  process  is  completed,  if  the  patient 
is  to  he  protected  against  an  attach  -of  erysipelas.  Another  important  fact 
should  always  be  remembered:  that  small  ivounds  are  more  frequently  at- 
tacked hy  erysipelas  than  large  wounds,  hecause  the  latter  receive  more  careful 
attention,  and  are,  as  a  rule,  subjected  to  more  rigid  aseptic  treatment. 

PEOGNOSIS. 

Simple  uncomplicated  erysipelas  is  not  a  fatal  disease  unless  it  attacks 
infants  or  persons  debilitated  by  age  or  antecedent  diseases.  Death  is  caused 
more  frequently  by  complications.  The  most  common  fatal  complications 
are  suppurative  inflammation  at  the  seat  of  erysipelatous  inflammation,  or 


430  PETNCIPLES    OF    SUEGERY. 

metastatic  suppuration  in  distant  parts  or  organs,  resulting  from  secondary 
infection  with  pus-microbes,  or,  finally,  extension  of  the  erysipelatous  in- 
flammation to  important  organs,  as  the  brain  or  its  envelopes,  in  cases  of 
facial  erysipelas,  or  the  occurrence  of  metastatic  erysipelas  in  vital  organs 
from  embolic  processes.  The  prognosis  is,  therefore,  based  largely  upon  the 
absence  or  presence  of  complications,  which  must  be  carefully  sought  for  in 
all  cases  where  general  or  local  symptoms  point  to  their  existence.  The 
temperature,  pulse,  and  condition  of  nervous  and  digestive  organs  furnish 
important  and  valuable  prognostic  indications. 

TREATMENT. 

The  number  of  specifics  which  at  different  times  have  been  recom- 
mended in  the  local  and  general  treatment  of  erysipelas  must  throw  doubt 
upon  the  efficacy  of  any  local  applications  or  internal  remedies  in  arresting 
the  further  progress  of  erysipelas.  At  the  same  time  it  must  not  be  for- 
gotten that  uncomplicated  erysipelas  is  a  disease  which  tends  to  spontane- 
ous recovery,  and  seldom  proves  fatal,  even  if  it  is  allowed  to  pursue  its  own 
course,  unaided  by  any  local  application  or  internal  medication.  The  ery- 
sipelatous inflammation  is  of  short  duration,  and  passes  through  its  different 
stages  uninfluenced  by  local  or  general  treatment.  Since  its  microbic  origin 
has  been  suspected  different  methods  of  treatment  have  been  recommended 
to  arrest  the  further  progress  of  the  disease  by  destroying  or  rendering  inert 
the  primary  cause.  Hueter  aimed  at  the  destruction  of  the  specific  microbe 
by  injecting,  at  different  points  at  the  border  of  the  erysipelatous  zone,  5  to 
6  cubic  centimetres  of  3-per-cent.  solution  of  carbolic  acid.  This  method  of 
treatment  in  the  hands  of  others  has  been  followed,  almost  without  excep- 
tion, by  negative  results.  It  is  possible  that  subcutaneous  injections  of  a 
1-to-lOOO  solution  of  corrosive  sublimate  in  non-toxic  doses  would  yield 
better  results.  The  continued  application  of  cold,  even  of  an  ice-bag,  has 
been  found  useless  in  arresting  the  disease.  As  it  has  been  found  that  a 
temperature  of  over  40°  C.  continued  for  two  days  has  at  least  an  inhibitory 
effect  on  the  growth  of  the  streptococcus  of  erysipelas  in  artificial  nutrient 
media,  it  would  appear  rational  to  resort  to  hot  antiseptic  compresses  in  the 
local  treatment  of  erysipelas.  If  the  area  involved  is  limited,  a  compress, 
saturated  with  a  weak  hot  solution  of  corrosive  sublimate  or  carbolic  acid, 
would  answer  a  most  admirable  purpose.  If  a  large  surface  is  affected,  some 
of  the  weaker  germicidal  solutions  could  be  used  in  the  same  manner. 
Moisture  and  heat  relieve  also  the  burning,  smarting  sensation  more 
promptly  and  effieiently  than  the  different  filthy  ,oils  and  salves  which  have 
been  employed.  Application  of  tincture  of  iodine,  muriated  tincture  of 
iron,  and  solutions  of  nitrate  of  silver  are  worse  than  useless,  because  they 
destroy  the  skin,  which  should  be  carefully  preserved  in  order  to  protect 


TKEATMENT.  431 

the  patient  against  secondary  infection  with  pus-microbes.  One  of  the  best 
local  applications  is  alcohol,  either  pure  or  slightly  diluted.  A  compress  well 
saturated  with  alcohol  is  applied  over  the  erysipelatous  area  and  evaporation 
is  prevented  by  applying  over  it  gutta-percha  or  some  other  impermeable 
cover,  and  the  whole  retained  by  a  gauze  bandage. 

Kraske  recommended  multiple  minute  incisions  or,  rather,  scarifica- 
tions in  the  skin,  at  the  peripheral  zone  of  the  erysipelatous  inflammation, 
for  the  purpose  of  preventing  farther  extension  of  the  disease.  If  the  skin 
is  first  rendered  aseptic,  and  subsequent  secondary  infection  is  guarded 
against  by  the  application  of  a  reliable  antiseptic,  this  treatment  may  prove 
valuable  in  modifying  the  progress  of  the  disease.  After  scarification  a  hot, 
moist,  sublimated  compress  should  be  applied,  to  be  immediately  replaced  by 
another  when  removed.  The  external  use  of  ichthyol,  so  highly  recom- 
mended by  ISTussbaum,  has  proved  useless  in  my  hands,  both  in  relieving 
suffering  and  in  preventing  the  extension  of  the  disease. 

St.  Klein  appears  to  have  obtained  better  results.  He  has  treated  31 
cases  of  erysipelas  with  ichthyol  applied  externally,  with  excellent  results. 
In  his  experience  the  disease  seldom  resisted  this  treatment  for  more  than 
three  or  four  days^  He  uses  a  preparation  composed  of  equal  parts  of 
ichthyol  and  vaselin,  which  is  applied  two  or  three  times  over  the  parts 
afEected.  Before  the  first  application  is  made  the  skin  is  thoroughly 
cleansed  with  warm  water  and  soap.  After  the  ointment  is  rubbed  in 
gently  the  surface  is  covered  with  a  compress  saturated  with  a  solution 
of  salicylic  acid  and  over  this  a  thick  layer  of  cotton.  Benoy  claims  that 
he  has  been  successful  in  aborting  erysipelas  in  about  60  per  cent,  of  his 
cases  by  local  applications  of  ichthyol  and  traumaticin. 

Wolfler  has  called  attention  to  the  value  of  the  mechanical  treatment 
of  erysipelas.  He  has  published  18  additional  cases  of  erysipelas  treated 
by  pressure  made  with  strong  adhesive  plaster.  After  the  plaster  is  applied 
the  disease  extends  into  the  compressed  parts  of  the  skin,  which  swell  con- 
siderably and  remain  swollen  for  several  days,  and  then  both  the  swelling 
and  the  fever  diminish.  He  recommends  that  by  way  of  precaution  a 
second  line  should  be  commenced  several  centimetres  distant  from  the 
first.  The  part  must  be  carefully  inspected  once  or  twice  daily  in  order 
to  detect  any  loosening  of  the  plaster.  Occasionally  the  erysipelatous  in- 
flammation extends  in  diminished  intensity  for  a  short  distance  beyond 
the  first  line  of  plaster,  but  this  does  not  last  long.  This  method  of  treat- 
ment is  at  least  harmless,  and  if  future  experience  should  prove,  as  it 
probably  will,  that  it  will  not  succeed  in  arresting  the  local  extension  of 
the  disease,  it  will  at  least  provide  an  efiicient  protection  for  the  inflamed 
skin. 

Phlegmonous  inflammation  and  metastatic  suppuration  should  be  pre- 


432  PRINCIPLES    OP    SURGERY. 

vented;,  as  far  as  possible^  by  the  employment  of  such  measures  as  will 
guard  against  the  formation  of  suppurating  foci  in  the  inflamed  skin. 
Bullge  should  be  evacuated  as  soon  as  they  form  by  puncturing  with  an 
aseptic  needle^,  carefully  preserving  the  cuticle  as  a  protection  against 
the  entrance  of  pyogenic  microbes.  Unfiltered  air  should  not  reach  the 
inflamed  skin,  and  for  this  purpose  it  should  be  covered  either  with  an 
antiseptic,  moist  compress,  or  a  thick  layer  of  antiseptic  cotton.  The  skin 
is  disinfected  in  advance  of  the  extension  of  the  disease,  and  is  subse- 
quently protected  against  additional  infection  by  applying  a  hot,  moist 
antiseptic  compress,  or  by  covering  it  with  antiseptic  absorbent  cotton. 
If  suppuration  take  place  in  the  interior  of  bullge  the  cuticle  should  be 
removed,  after  which  the  surface  is  carefully  disinfected  by  irrigation 
with  a  germicidal  solution,  followed  by  an  application  of  a  10-per-cent. 
solution  of  chloride  of  zinc,  and  further  infection  prevented  by  an  anti- 
septic dressing.  If  phlegmonous  inflammation  develop  in  spite  of  these 
prophylactic  measures,  early  and  free  incisions  are  made,  free  drainage 
established,  and  a  subsequent  treatment  followed  out  appropriate  for 
phlegmonous  inflammation  not  complicated  by  erysipelas.  Gangrene  of 
the  skin  is  to  be  treated  by  applying  a  hot  antiseptic  compress  until  the 
dead  tissue  is  eliminated,  when  the  defect  is  replaced  by  skin-grafting. 
Internal  medication  has  even  been  less  satisfactory  than  the  local  meas- 
ures in  the  treatment  of  erysipelas.  During  the  febrile  stage  the  admin- 
istration of  the  tincture  of  ferric  chloride  and  the  mineral  acids  does  more 
harm  than  good.  If  the  temperature  is  high,  a  daily  antipyretic  dose  of 
quinine  is  indicated,  and  exerts  a  favorable  influence  upon  the  local  process 
and  the  general  condition  of  the  patient.  If  the  patient  is  restless  a  full 
dose  of  Dover's  powder  shoiild  be  given  at  bed-time.  Symptoms  of  pros- 
tration are  met  early  by  the  use  of  a  substantial  wine  or  some  other 
alcoholic  stimulant. 

Symptoms  of  collapse  are  treated  by  administering  internally  1  ^/g 
grains  of  camphor  every  hour,  or  the  same  amount  of  the  drug  is  dis- 
solved in  oil  of  sweet  almonds  and  injected  subcutaneously  every  half- 
hour  or  hour  until  symptoms  of  intoxication,  delirium,  and  reduction  of 
the  pulse  to  50  or  55  beats  per  minute  are  produced.  The  camphor  treat- 
ment in  grave  cases  of  erysipelas  was  introduced  by  Pirogoff,  and  has 
yielded  excellent  results  when  the  threatening  symptoms  point  to  an 
enfeebled  heart. 

This  is  the  proper  place  to  mention  the  antistreptococcic  serum  of 
Marmorek  as  a  therapeutic  agent  in  the  treatment  of  streptococcic  in- 
fection. This  serum  has  received  a  fair  trial  since  1895,  and  the  general 
experience  has  been  very  unfavorable  indeed,  including  Marmorek's  statis- 
tics.    A  committee  appointed  by  the  American  G-ynsecological  Society  to 


EKYSIPELOID.  433 

investigate  its  merits  reported  adversely.  Parascandolo  has  investigated 
the  relation  of  the  streptococcus  pyogenes  to  the  streptococcus  of  erysipe- 
las. He  finds  that  the  serum  of  an  animal  immunized  to  one  of  these  or- 
ganisms prevents  a  growth  of  the  culture  of  the  same  organism  and  saves 
animals  that  have  been  injected  with  such  cultures;  but  neither  organism 
has  the  same  protective  power  against  the  other;  so  that  the  author  be- 
lieves that  the  organisms  are  different  and  that  the  treatment  of  erysipelas 
by  antistreptococcic  serum  must  be  prepared  from  the  streptococcus  of 
erysipelas.  He  has  found  the  best  method  of  immunization  is  by  the  use 
of  the  toxins,  and  not  by  the  employment  of  virulent  cultures.  Serum- 
therapy  in  the  treatment  of  streptococcic  infection — pyogenic  and  erysipel- 
atous— at  the  present  time  is  in  a  very  unsettled  and  unsatisfactory  state, 
and  it  is  very  doubtful  if  much  can  be  expected  from  this  source  in  the 
future. 

ERYSIPELOID. 

A  new  form  of  infective  dermatitis,  which  in  many  respects  resembles 
erysipelas,  was  described  by  Eosenbach  in  1883  under  the  name  of  "ery- 
sipeloid.^^ It  attacks  usually  the  fingers  and  exposed  portion  of  the  hand, 
and  is  most  frequently  met  with  in  persons  who  handle  game  or  dead  ani- 
mals, as  cooks,  butchers,  fish-dealers,  and  tanners.  The  affection  starts 
from  some  minute  abrasion  of  the  skin  as  a  bluish-red  infiltration,  which 
slowly  advances  in  an  upward  direction.  The  inflamed  parts  are  the  seat 
of  a  burning,-  smarting  sensation.  While  the  skin  at  the  point  of  infec- 
tion returns  to  its  natural  condition  and  color,  the  zone  of  infiltration 
becomes  larger,  as  it  continues  to  spread  until  the  disease  appears  to  ex- 
haust itself  in  the  course  of  from  one  to  three  weeks.  The  infectious 
material  which  produces  this  disease  is  contained  in  decomposing  animal 
substances.  Infection  may  occur  in  any  abraded  part  of  the  body  which 
comes  in  contact  with  material  containing  the  virus.  The  temperature 
remains  normal,  and  the  general  health  is  not  affected.  The  inflammation 
travels  very  slowly,  so  that  if  infection  take  place  in  the  tip  of  a  finger 
it  reaches  the  metacarpo-phalangeal  joint  in  about  eight  days,  and  during 
the  second  week  it  spreads  over  the  back  of  the  hand,  from  where  an  ad- 
jacent finger  may  become  affected,  the  extension  then  taking  a  direction 
opposite  to  the  lymph-current.  Eepeated  experiments  to  obtain  a  pure 
culture  of  the  microbe  failed,  until  in  ISTovember,  1886,  the  author  suc- 
ceeded in  cultivating  it  upon  gelatin  from  a  case  in  which  the  disease  could 
be  traced  to  infection  from  old  cheese. 

Rosenbach  injected  a  pure  culture  under  the  skin  of  his  own  arm 
at  three  different  points.  After  forty-eight  hours  he  experienced  a  smart- 
ing, burning  sensation  at  the  points  of  injection;    at  the  same  time  a 


434  PEINCIPLES    OF    SUEGERY, 

circumscribed  redness  appeared  around  each  puncture,  which  soon  became 
confluent.  On  the  fifth  day  each  puncture  was  surrounded  by  a  zone  of 
inflammation  the  size  of  a  silver  dollar,  somewhat  elevated  above  the 
niveau  of  the  surrounding  skin.  While  the  centre  of  this  red  patch  be- 
came pale,  the  zone  of  inflammation  continued  to  enlarge.  In  the  in- 
flamed skin  the  capillary  vessels  could  be  seen  dilated:  a  condition  of  the 
circulation  which  imparted  to  the  tissues  an  arterial  hue  with  a  slight 
tinge  of  brown,  while  inside  of  the  zone  the  color  was  a  livid  brown.  In 
the  skin  which  had  returned  to  its  normal  pale  color  slight  suggillations 
appeared,  as  though  some  of  the  red  blood-corpuscles  in  the  tissues  had 
been  destroyed  during  the  progress  of  the  disease.  The  inflammation 
appeared  to  have  completely  subsided  on  the  eighth  day,  when  the  smart- 
ing sensation  returned,  and  a  new  zone  appeared  around  the  old  one.  On 
the  tenth  day  the  area  measured  in  its  transverse  diameter  24  centimetres, 
and  in  the  parallel  direction  of  the  arm  18  centimetres. 

After  this  the  affection  disappeared  permanently.  During  all  this 
time  the  general  health  remained  unimpaired,  and  the  temperature  varied 
from  36.8°  to  37.2°  C.  A  microscopical  examination  of  the  pure  culture 
showed  that  it  was  composed  of  swarms  and  heaps  of  irregular,  round,  and 
elongated  bodies  somewhat  larger  in  size  than  the  staphylococcus.  The 
author  first  believed  that  these  bodies  were  cocci,  but  later  he  saw  a  net- 
work of  intertwining  threads,  and  decided  that  they  were  thread-forming 
microbes.  In  old  cultures  the  threads  were  very  abundant,  and  arranged 
in  every  possible  way  and  direction.  These  threads  appeared  as  though 
branches  were  given  off,  but  on  closer  examination  it  could  be  seen  that 
no  organic  connection  existed  between  them.  Terminal  spores  at  the  tips 
of  the  threads  were  numerous  and  could  not  be  stained.  Neither  the 
microbes  nor  the  threads  manifested  motile  power  in  the  culture,  or  when 
suspended  in  water;  a  gelatin  culture  became  visible  on  the  fourth  day 
as  a  delicate  cloud,  which  increased  in  size  very  slowly  at  a  temperature 
of  20°  C.  The  older  cultures  change  into  a  brownish-gray  color,  and  then 
resemble  the  culture  of  the  bacillus  of  septicaemia  in  mice.  In  cultures 
4  months  old  the  growth  was  not  entirely  suspended.  The  author,  as  yet, 
has  not  given  a  name  to  this  microbe,  but  believes,  on  botanical  grounds, 
that  it  belongs  to  the  "cladothrix"  variety  of  microorganisms.  He  wished 
to  ascertain  the  action  of  this  microbe  on  lupus,  but  in  several  cases  in 
which  it  was  tried  the  inoculations  failed.  Erysipeloid  is  a  harmless  form 
of  infection,  and  subsides  spontaneously  in  the  course  of  two  or  three 
weeks.  I  have  seen  a  number  of  cases  in  persons  handling  fish  and  game, 
where  the  affection  started  in  one  of  the  fingers,  extended  slowly  as  far 
as  the  dorsum  of  the  hand,  and  then  gradually  invaded  an  adjacent  finger 
and  the  back  of  the  hand  as  far  as  the  wrist.    In  the  cases  that  have  come 


EKYSIPELOID.  435 

under  my  observation  the  inflammation  never  extended  beyond  the  wrist. 
The  disease  is  self-limited,  and  its  local  extension  is  not  arrested  by  any 
topical  applications. 


CHAPTEE  XYII. 

Tetanus. 

The  wound-infective  diseases  in  which  the  microbes  or  their  toxins 
act  upon  the  central  nervous  system  are  represented  by  tetanus  and  hydro- 
phobia. The  specific  microbes  which  are  the  cause  of  these  diseases  pro- 
duce no  gross  pathological  changes  in  the  brain  or  spinal  cord,  but  the 
minute  tissue-changes  cause  a  central  irritation,  which  is  manifested  by 
spasm  of  certain  definite  muscular  groups.  Tetanus  is  an  infective  disease 
in  which  the  specific  microbic  cause  exerts  its  pathogenic  action  on  the 
central  nervous  system,  and  which  is  clinically  characterized  by  spasm  and 
rigidity  of  definite  muscular  groups. 

BACTEEIOLOGICAL    STUDIES. 

The  classification  of  tetanus  with  the  infectious  diseases  is  of  recent 
date,  but  the  infectious  nature  of  the  disease  was  well  known  and  estab- 
lished before  the  discovery  of  the  bacillus  tetani.  In  1859  Betoli  related 
the  case  of  a  bull  that  died  of  tetanus  after  castration.  Several  slaves 
ate  some  of  the  flesh  of  the  dead  animal,  and  of  these  3  were  (in  a  few 
days)  seized  with  tetanus  and  2  of  them  died.  He  adds,  further,  that 
in  Brazil,  where  this  occurred,  the  flesh  of  animals  dead  of  tetanus  is 
generally  regarded  as  capable  of  transmitting  the  disease.  In  1870  Anger 
reported  a  case  in  which  a  horse  had  spontaneous  tetanus,  after  which 
3  puppies  which  had  been  in  the  same  stable  were  also  affected.  Larger, 
in  1853,  saw  a  woman  who  had  a  fall  while  cleaning  a  farm-yard,  causing 
a  slight  wound  of  the  elbow.  Four  weeks  later  she  was  seized  with  tetanus, 
and  on  investigation  it  was  found  that  a  horse  affected  with  that  disease 
had  been  in  a  stable  opening  into  the  yard  where  she  fell.  He  also  men- 
tions another  circumstance  which  strongly  points  to  the  infectious  nature 
of  tetanus.  In  a  small  village,  where  tetanus  was  previously  unknown, 
5  cases  appeared  in  eighteen  months  under  quite  different  climatic  con- 
ditions. Of  these,  1  had  been  taken  to  a  hospital,  after  which  2  others  in 
the  same  ward  became  affected  with  the  disease.  In  1884  Carle  and  Eat- 
tone  produced  the  disease  artificially  in  animals  by  inoculations  Mdth  pus 
from  tetanic  patients.  Nearly  at  the  same  time  the  real  microbic  cause 
of  tetanus  was  discovered  by  Mcolaier  and  Eosenbach.  ISTicolaier  showed 
the  exogenous  origin  of  the  disease  by  finding  a  bacillus  in  earth  which 
produced  tetanus  in  animals  when  injected  into  the  tissues.  Eosenbach 
found  the  same  bacillus  in  the  pus  of  a  patient  suffering  from  traumatic 
tetanus.  The  identity  of  the  bacillus  of  tetanus  with  Mcolaier's  bacillus- 
of-earth  tetanus  was  demonstrated  in  Koch's  laboratory,  April  10,  1887. 

(436) 


BACTERIOLOGICAL    STUDIES.  437 

Bacillus  Tetani. — Eosenbach  describes  the  bacillus  as  an  anaerobic 
microorganism  wliich  presents  a  bristly  appearance,  with  a  spore  at  one 
of  its  extremities  which  gives  it  the  resemblance  to  a  pin  or  drum-stick. 

According  to  Kitasato,  the  bacilli  produce  spores  in  thirty  hours  in 
cultures  kept  at  a  temperature  of  the  body.  They  possess  great  resistance 
to  heat,  as  they  have  been  found  active  after  an  exposure  of  one  hour  to 
80°  C.  of  moist  heat,  but  they  are  destroyed  by  placing  them  in  a  steril- 
izer heated  to  100°  C.  for  five  minutes.  The  bacillus  has  been  found  in 
different  kinds  of  surface  soil  and  in  street-dust.  In  man  it  has  been 
found  in  tetanic  patients  in  the  wound-secretions,  in  the  nerves  leading 
from  the  seat  of  infection,  and  in  the  spinal  cord. 


Fig.  158. — Tetanus  Bacilli.     Spore-bearing  rods  from  an  agar  culture.     Mounted  prepa- 
rations, stained  with  fuchsin.     X  1000.     (Frdnkel-Pfeiffer.) 

Cultivation. — Eosenbach  found  it  impossible  to  obtain  a  pure  culture; 
although  he  resorted  to  fractional  cultivation,  it  Avas  found  that  the  last 
culture  was  still  contaminated  by  one  or  more  additional  microbes. 
Flligge  claimed  to  have  obtained  a  pure  cultivation  by  heating  for  five 
minutes  the  mixed  culture  to  100°  C,  but  after  this  procedure  the  bacillus 
was  incapable  of  further  j)ropagation.  After  many  trials  it  was  found 
that  sterilized  solid  blood-serum  was  the  best  soil  for  the  propagation  of 
the  bacillus  outside  of  the  body.  Both  Nicolaier  and  Eosenbach  observed 
the  anaerobic  nature  of  the  bacillus,  as  it  was  found  impossible  to  obtain 
a  culture  by  streak  inoculations,  or  in  any  other  manner  by  which  oxygen 
could  not  be  excluded.  The  culture  appeared  slowly,  as  a  delicate, 
whitish-gray  film,  in  the  track  of  the  stab  inoculation,  below  the  surface 
of  the  culture-substance.     By  a  long  series  of  cultures  Eosenbach  finally 


438 


PEINCIPLES    OF    SUEGERY. 


succeeded  in  eliminating  all  other  microbes  with  the  exception  of  a  bacil- 
lus of  putrefaction.  The  growth  of  the  bacillus  takes  place  most  readily 
at  an  equable  temperature  of  37°  C.  (98.6°  F.),  and  becomes  first  visible 
about  the  third  day  in  the  depths  of  the  culture-media.  Kitasato  finally 
succeeded  in  obtaining  a  pure  culture  of  the  bacillus  of  tetanus  from  pus 
taken  from  a  patient  suffering  from  this  disease.  As  the  bacillus  will 
only  grow  where  atmospheric  air  can  be  excluded,  he  exposed  his  cultures 
to   hydrogen-gas   with    complete    exclusion   of    oxygen.      Mixed   cultures, 


Fig.  159.— Culture  of  Bacillus  Tetani  in  Nutrient  Gelatin.     (^Kitasato.) 

which  had  been  kept  for  several  days  in  the  incubator,  were  then  exposed 
for  half  an  hour  to  a  temperature  of  80°  C.  Further  growth  was  then 
obtained  upon  plate  cultures  in  closed  glass  vessels  filled  with  hydro- 
gen-gas. By  heating  the  mixed  culture  to  80°  C.  he  destroyed  all  microbes 
with  the  exception  of  the  bacillus  of  tetanus,  which,  later,  was  cultivated 
upon  solid  nutrient  media  in  an  atmosphere  of  hydrogen-gas.  At  a  tem- 
perature of  18°  to  20°  C.  a  visible  culture  appeared  at  the  end  of  a  week. 
If  the  temperature  was  increased  to  blood-heat  the  bacilli  and  spores  de- 
veloped more  rapidly. 


BACTEKIOLOGICAL    STUDIES.  439 

Inoculation  Experiments. — Nicolaier  produced  tetanus  in  rabbits  and 
mice,  experimentally,  by  inoculations  with  different  kinds  of  surface  soil. 
Out  of  140  experiments  in  69  a  disease  was  joroducecl  identical  with  tetanus 
in  man.  In  the  pus,  at  the  point  of  inoculation,  bacilli  and  micrococci 
were  constanly  found.  Among  the  bacilli  one  form  was  constantly  pres- 
ent; this  bacillus  resembled  in  appearance  and  culture  the  bacillus  of 
septicaemia  in  mice,  but  was  more  slender.  This  bacillus  was  found  in 
isolated  places  in  the  connective  tissue,  but  could  not  be  found  in  the 
muscles,  nerves,  and  blood.  Earth  sterilized  by  exposing  it  to  a  high  tem- 
perature for  an  hour  proved  harmless,  showing  conclusively  that  the  con- 
tagium  of  tetanus  had  been  destroyed.  Inoculations  with  pus  taken  from 
tetanic  animals  were  most  successful.  Inoculations  with  mixed  cultures 
grown  in  solidified  blood-serum  yielded  positive  results. 

Eosenbach  made  his  experiments  with  mixed  cultures  grown  from 
pus  taken  from  the  line  of  demarcation  of  a  case  of  frost  gangrene  in 
a  patient  who  had  died  of  tetanus.  The  inoculations  proved  successful. 
Bonome  reports  the  case  of  a  man  suffering  from  paraplegia,  the  result 
of  disease  of  the  spine  in  the  dorsal  region,  complicated  by  an  extensive 
sacral  decubitus,  the  seat  of  phlegmonous  inflammation,  who  was  sud- 
denly attacked  by  tetanus,  which  j)roved  fatal  in  two  days.  One  hour 
after  death  a  small  portion  of  the  infiltrated  tissue  around  the  gangre- 
nous part  was  removed,  and  after  reducing  it  to  a  fine  pulp  by  tritura- 
tion he  injected  it  under  the  skin  of  a  rabbit.  Twenty-two  hours  after 
inoculation  the  animal  died  with  well-marked  symptoms  of  tetanus.  The 
products  of  inflammation  from  the  point  of  injection  thrown  into  the  sub- 
cutaneous tissue  of  other  animals  produced  the  disease,  while  intravenous 
injections  proved  harmless.  The  gravity  of  symptoms  following  subcuta- 
neous injections  was  commensurate  with  the  quantity  of  fluid  injected. 
Guinea-pigs  proved  less  susceptible  to  infection  than  rabbits.  In  the  pus 
taken  from  the  dead  tissue  he  found,  besides  the  usual  pus-microbes,  a 
bacillus  which  resembled  in  every  respect  the  one  described  by  Nicolaier 
and  Eosenbach.  Hochsinger  made  his  observations  on  a  case  of  tetanus 
which  proved  fatal  on  the  fifth  day.  The  day  before  the  patient  died  blood 
was  abstracted  from  a  vein,  under  strict  antiseptic  precautions,  for  micro- 
scopical and  bacteriological  study.  No  microorganisms  could  be  found  in 
it.  With  the  greatest  care,  sterilized,  solid  blood-serum  was  inoculated 
with  the  blood,  by  making,  with  the  needle,  both  superficial  streaks  and 
deep  punctures.  The  nutrient  medium  was  kept  at  a  temperature  of 
37°  C.  (98.6°  F.).  On  the  third  day  a  white,  cloudy  streak  marked  the 
direction  of  the  deep  punctures,,  while  the  superficial  plant  remained 
sterile.  On  the  same  day  a  portion  of  the  culture  was  removed  and  stained 
with  aniline  gentian,  and  the  characteristic  bacillus  was  found.     A  large 


440  PEINCIPLES    OF    SUEGEEY. 

rabbit  was  infected  by  injecting  blood  obtained  from  the  patient  during 
life.  The  blood  was  diluted  with  sterilized  water^  and  a  syringeful  of  this 
mixture  was  injected  under  the  skin  in  the  iliac  region,  and  half  of  this 
quantity  under  the  skin  of  the  left  thigh.  The  next  day  the  animal  was 
quite  ill  and  unable  to  use  the  left  hind-leg,  which  was  dragged  along  in 
walking.  At  this  time  great  nervous  excitability  was  observed,  the  exag- 
gerated reflex  symptoms  being  especially  well  marked  in  the  posterior  ex- 
tremities, which,  on  the  slightest  touch,  were  thrown  into  clonic  spasm. 
On  the  following  day  the  animal  was  found  dead.  A  few  hours  before 
death  well-marked  symptoms  of  tetanus  developed.  Injections  of  blood 
from  this  animal  produced  no  results  in  other  rabbits,  and  culture  experi- 
ments were  equally  fruitless.  A  syringeful  of  inspissated  blood  of  the  pa- 
tient, kept  for  three  weeks,  thrown  under  the  skin  of  a  white  mouse,  was 
followed  by  a  fatal  attack  of  tetanus,  while  a  second  animal  inoculated 
in  a  similar  manner  with  one-half  of  this  quantity  remained  perfectly  well. 

Miigge  had  before  observed  that,  by  injecting  blood  from  animals 
rendered  tetanic  by  inoculation,  it  was  necessary  to  use  a  large  quantity  in 
order  to  reproduce  the  disease  in  other  animals,  and  even  by  doing  so 
the  result  was  not  always  satisfactory.  It  appears  that  the  blood  of  te- 
tanic patients  possesses  greater  toxic  properties  than  the  blood  of  animals 
suffering  from  the  same  disease.  Hochsinger  also  made  inoculations  with 
the  mixed  cultures.  A  syringeful  of  a  liquid  culture  was  injected  into  the 
subcutaneous  tissue  of  a  medium-sized  rabbit.  The  next  day  the  reflexes 
were  increased,  respiration  more  rapid,  and  the  animal  appeared  otherwise 
quite  sick.  On  the  third  day  the  posterior  extremities  were  stiff,  the  ani- 
mal dragging  them  in  walking;  reflex  irritability  enormously  exaggerated. 
On  the  fifth  day  the  animal  died,  with  well-marked  symptoms  of  tetanus. 
A  number  of  similar  successful  experiments  are  reported  by  the  same 
author.  In  rabbits  Fliigge  estimated  the  stage  of  incubation  at  from  three 
to  five  days,  and  the  duration  of  the  disease,  from  the  time  the  first  symp- 
toms were  noticed  to  the  fatal  termination,  from  five  to  seven  days. 

Beumer  gives  an  accurate  and  able  description  of  his  studies  in  2 
cases  of  tetanus.  The  first  case  occurred  in  a  mechanic,  who  injured 
himself  under  the  nail  of  the  right  middle  finger  with  a  splinter  of  wood. 
Eight  days  after  the  injury,  the  patient  having  had  but  slight  pain  in  the 
finger,  pains  appeared  in  the  neck  and  muscles  of  the  back.  The  next 
morning  spasms  of  the  muscles  of  the  chest,  abdomen,  and  jaw  developed. 
These  attacks  occurred  at  intervals  of  an  hour  and  a  half.  Four  days  later 
the  lower  extremities  were  affected,  also  the  upper,  but  in  a  less  degree. 
An  incision  was  made  and  the  foreign  body  removed,  which  was  followed 
by  the  escape  of  a  drop  of  pus;  death  on  the  fourth  day.  The  second  case 
was  a  boy  6  ^/^  years  old,  who  was  brought  into  the  clinic  with  well-marked 


BACTEEIOLOGIOAL    STUDIES.  441 

symptoms  of  tetanus,  and  who  lived  only  a  few  hours  after  his  admission. 
The  author  obtained  some  of  the  dust  and  splinters  of  wood  from  the 
place  where  the  mechanic  had  injured  himself,  and  inserted  small  particles 
under  the  skin  of  mice  and  rabbits.  In  all  experiments  the  animals  were 
attacked  with  tetanus  in  from  two  to  three  days  after  inoculation,  and  died 
during  the  third  or  fourth.  The  spasms  were  always  noticed  first  in  the 
muscles  nearest  the  point  of  inoculation.  A  fragment  of  tissue  from  the 
sole  of  the  foot  was  taken  from  the  boy,  and  small  particles  of  it  inserted 
into  the  subcutaneous  tissue  of  6  mice.  In  all  of  these  symptoms  of  tet- 
anus appeared  after  two  days,  developing  gradually  into  general  convul- 
sions and  death. 

The  same  results  were  obtained  in  mice  and  rabbits  by  inoculations 
of  particles  of  dust  taken  from  the  spot  where  the  boy  sustained  the  in- 
jury. The  same  author  also  made  numerous  experiments  with  different 
kinds  of  earth.  Of  10  experiments  with  soil  taken  from  the  ocean-beach, 
tetanus  followed  in  only  2.  On  the  other  hand,  of  10  inoculations  with 
garden-earth  and  street-dust,  all  proved  successful  but  1.  Of  the  greatest 
scientific  and  practical  interest  are  the  observations  made  by  Bonome,  in 
reference  to  the  causation  of  tetanus  by  infection  with  earth  containing 
the  bacillus  discovered  by  Kicolaier.  He  had  an  opportunity  to  observe 
a  number  of  cases  of  tetanus  after  the  earthquake  at  Bajardo.  Of  the 
70  persons  injured  in  the  ruins  of  the  church,  7  were  attacked  by  tetanus. 
From  bacteriological  investigations  in  connection  with  these  cases  he 
came  to  the  same  conclusions  in  regard  to  the  cause  of  the  disease  as 
Nicolaier,  Eosenbach,  Flugge,  and  Beumer  before  him.  Of  special  im- 
portance is  the  observation  made  by  him,  that  the  secretions  from  the 
wounds  and  the  exudation  from  the  part,  the  seat  of  tetanic  convulsions, 
when  dried  and  preserved  between  two  sterilized  watch-glasses,  retained 
their  virulent  properties  for  at  least  four  months.  All  animals  inoculated 
with^dust  from  the  debris  in  the  interior  of  the  church  were  attacked  with 
tetanus.  Control  experiments  with  dust  from  the  ruins  at  Diano-Marina 
were  always  followed  by  negative  results.  Of  the  many  persons  injured 
during  the  same  earthquake  at  this  place,  not  one  was  attacked  by  tetanus. 

Ohlmliller  and  Goldschmidt  made  a  thorough  bacteriological  investiga- 
tion of  a  case  of  tetanus  following  complicated  fracture  of  the  right  thumb. 
The  disease  appeared  the  day  following  the  injury,  and  proved  fatal  in 
seventeen  hours.  Soon  after  death  inoculation  experiments  were  made 
with  blood  taken  from  the  heart  and  spleen,  and  pus  from  the  seat  of 
fracture.  The  cultures  were  grown  in  solid  blood-serum  kept  at  a  tem- 
perature of  38°  C.  (100.7°  F.).  The  tubes  containing  blood  from  the 
heart  and  spleen  remained  sterile,  but  the  nutrient  media  infected  with 
pus  showed  signs  of  growth.     The  bacilli  which  were  detected  resembled 


442  PRINCIPLES    OP    SUEGERY. 

those  of  mouse-septicsemia,  only  somewhat  larger  in  size.  In  addition  to 
these  microhes  streptococci  and  a  thick  bacillus  were  found.  Two  mice 
were  inoculated  with  this  mixed  culture.  Twelve  hours  after  infection 
tetanus  developed^  followed  by  death  in  seventeen  hours.  The  spasms 
commenced  in  the  tail,  extended  to  the  posterior  extremities,  and  then 
gradually  advanced  in  a  forward  direction.  From  these  animals  blood- 
serum  was  taken,  Avith  which  other  mice  were  infected.  Again  tetanus 
was  produced,  and  successful  cultivations  were  made  from  2  mice  of  equal 
size  and  age;  1,  which  received  one  portion  of  a  culture,  died  of  tetanus 
on  the  ninth  day,  while  the  other,  which  received  a  dose  three  times  as 
large,  died  on  the  third  day.  Of  3  cases  of  tetanus  which  came  under  the 
observation  of  Lumniczer,  he  was  able  to  demonstrate  the  microbic  origin 
in  1.  In  this  ease  the  attack  followed  a  gunshot  injury.  After  the  disease 
had  developed  fragments  of  hemp  were  removed  from  the  canal  made  by 
the  bullet,  and  in  them  the  characteristic  bacillus  was  found.  Cultures  were 
made  to  the  tenth  generation,  and  with  them  animals  were  inoculated,  and 
tetanus  was  invariably  produced.  Pus  taken  from  abscesses  produced  at  the 
point  of  inoculation  contained  the  bacillus,  and  inoculation  experiments 
made  with  it  yielded  positive  results.  Cultures  made  from  the  blood  or  or- 
gans of  the  tetanic  animals  remained  sterile.  Inoculations  with  blood  from 
these  animals  proved  harmless. 

Kitasato  experimented  with  a  pure  culture  of  the  bacillus  of  tetanus 
on  mice,  rats,  guinea-pigs,  and  rabbits,  and  never  failed  in  producing  the 
disease,  provided  a  sufficiently  large  dose  of  the  culture  was  adminis- 
tered. In  mice  the  disease  appeared,  without  exception,  twenty-four  hours 
after  the  inoculation,  and  proved  fatal  in  two  to  three  days.  The  tetanic 
convulsions  were  first  always  local,  appearing  first  in  the  muscles  nearest 
the  point  of  inoculation,  and  becoming  gradually  more  diffuse.  He  was 
unable  to  find  the  bacillus  at  the  seat  of  inoculation,  the  blood,  or  in  any 
of  the  internal  organs.  He  is  of  the  opinion  that  if  tetanus  is  produced  by 
inoculation  with  a  pure  culture  the  bacilli  do  not  remain  in  the  body  for 
any  length  of  time,  but  are  rapidly  eliminated.  The  experiments  and 
clinical  observations  which  have  just  been  quoted  furnish  conclusive  proof 
that  tetanus  is  a  microbic  disease,  and  that  the  bacillus  of  tetanus  dis- 
covered by  Mcolaier  and  Eosenbach  is  its  essential  cause.  Whether  culti- 
vations from  chronic  cases  of  tetanus  can  produce  an  acute  and  rapidly- 
fatal  attack  in  animals  remains  to  be  determined.  In  this  direction  I 
made  an  observation  which,  if  not  convincing,  is  at  least  very  suggestive.  A 
boy  15  years  of  age,  previously  in  good  health,  was  attacked  with  acute  osteo- 
myelitis in  the  lower  extremity  of  the  femur.  The  surgeon  in  attendance 
trephined  the  bone  just  above  the  external  condyle  during  the  first  few  days, 
and  before  an  abscess  had  formed  in  the  soft  parts.    A  few  days  after  the 


BACTEEIOLOGICAL    STUDIES.  ,  443 

operation  trismus  set  in,  followed  by  typical  chronic  tetanus.  Six  weeks  later 
the  patient  came  under  my  care.  At  this  time  the  patient  had  become 
emaciated  to  a  skeleton. 

Trismus  and  opisthotonos  were  well  marked,  and  the  lower  extremi- 
ties were  rigid  and  fixed  in  the  extended  position.  The  slightest  touch, 
or  a  draught  of  air  in  the  room,  would  bring  on  intense  convulsive  attacks 
for  several  minutes,  attended  by  excruciating  pain.  Profuse,  fetid  dis- 
charge at  the  site  of  operation;  pulse,  140;  temperature,  from  99°  to 
101°  P.  (37.3°  to  38.8°  C).  Believing  that  the  primary  infection  had 
taken  place  through  the  operation  wound,  and  that  the  osteomyelitic 
products  served  the  purpose  of  a  nutrient  medium  for  the  bacillus  tetani, 
I  determined  to  operate  in  spite  of  the  grave  symptoms.  As  the  spinal 
cord  at  this  stage  of  the  disease  was  necessarily  the  seat  of  intense  con- 
gestion, I  resorted  to  chloroform  as  an  auEesthetic  in  preference  to  ether. 
The  usual  operation  for  necrosis  of  the  lower  end  of  the  femur  was  made, 
and  a  large  triangular  sequestrum  removed  from  the  lower  and  posterior 
aspect  of  the  bone.  The  involucrum  was  defective,  and  its  inner  surface 
was  found  lined  with  a  thick  layer  of  flabby  granulations.  Gelatin  tubes 
were  inoculated  with  blood,  pus,  and  granulation-tissue.  The  tube  inocu- 
lated with  blood  remained  sterile,  while  the  two  remaining  tubes  showed 
a  copious  growth  of  staphylococcus  pyogenes  albus,  which  rapidly  liquefied 
the  gelatin.  A  portion  of  the  granulation-tissue  was  disinfected  with  a 
weak  solution  of  carbolic  acid,  dried  between  layers  of  antiseptic  gauze, 
and  inserted  under  the  skin  of  a  full-grown,  large  rabbit.  No  suppuration 
followed,  and  the  animal  remained  perfectly  well  for  six  weeks,  when  both 
posterior  extremities  became  rigid  and  could  not  be  used  in  walking.  The 
next  day  tetanic  convulsions  affecting  the  muscles  of  the  back  and  all  the 
limbs  appeared,  and  on  the  fourth  day  death  supervened. 

The  interesting  features  in  this  case  are  that  the  patient  recovered 
from  the  tetanus  after  a  long  illness,  extending  over  three  months;  that 
marked  improvement  followed  the  operation,  which  had  for  its  object 
thorough  disinfection  of  the  infection-atrium;  and  that  the  inoculation 
with  granulation-tissue  in  the  rabbit  was  followed  by  an  acute  attack  of 
tetanus  after  an  incubation  stage  extending  over  six  weeks.  In  the  ex- 
periments related  above  the  animals  were  inoculated  with  cultures,  earth, 
other  infected  foreign  substances,  fragments  of  diseased  tissue,  or  with 
wound-secretions  from  tetanic  patients;  the  stage  of  incubation  rarely  ex- 
tended over  two  or  three  days,  and  often  the  spasms  appeared  in  eighteen 
to  twenty-four  hours,  and  the  disease  produced  death  in  from  two  hours 
to  three  days. 

The  same  question  has  been  raised  in  connection  with  the  pathogenic 
action  of  the  bacillus  of  tetanus  as  with  pus-microbes:    Is  the  disease  of 


444  PEINCIPLES    OP    SUEGERY. 

which  it  is  the  specific  cause  due  to  tlie  presence  of  the  microhe,  or  the 
toxins  which  it  elaborates  in  the  tissues? 

Toxins  of  the  Bacillus  Tetani. — Brieger,  by  his  indefatigable  labors, 
has  demonstrated  beyond  all  doubt  that  the  toxins  of  the  bacillus  of  tet- 
anus cause  tetanic  convulsions.  Strychnia  in  toxic  doses  produces  a  con- 
dition which,  so  far  as  the  muscular  spasms  are  concerned,  closely  re- 
sembles tetanus.  If  this  and  other  drugs  belonging  to  the  same  group  can 
act  upon  the  spinal  cord  in  such  a  manner  as  to  cause  spasms  and  mus- 
cular rigidity,  we  should,  a  priori,  expect  that  if  the  microbe  of  tetanus 
produce  toxins  in  the  tissues  these  might  produce  the  same  effect  on  the 
cord,  and  that  the  symptoms  are  produced  by  them  and  not  by  the  direct 
action  of  the  microbe.  Nearly  all  authorities  are  agreed  that  the  bacilli 
present  in  the  blood  of  tetanic  patients  are  few,  and  in  animals  in  which 
the  disease  was  produced  artificially  the  blood  was  often  found  sterile. 
More  microbes  have  been  found  at  the  seat  of  primary  infection,  and  in 
the  tissues  between  it  and  the  spinal  cord,  than  in  the  blood  itself:  an- 
other proof  that  the  direct  cause  of  the  disease  is  the  product  of  the 
microbes,  and  not  the  microbes  themselves.  Brieger  has  succeeded  in 
isolating  four  toxic  substances  from  mixed  cultures  of  the  tetanus  bacillus 
in  sterilized  emulsion  of  meat.  The  first,  tetanin,  in  doses  of  a  few  milli- 
grammes, administered  subcutaneously  in  mice,  produced  the  characteris- 
tic s3anptoms  of  tetanus.  The  second,  tetainotoxin,  causes,  first,  tremors; 
later,  paralysis  and  convulsions.  The  third,  muriate  of  toxin,  has  not  been 
designated  by  a  special  name;  it  produces  also  well-marked  symptoms  of 
tetanus,  but,  besides,  excites  the  salivary  and  lacrymal  glands  to  in- 
creased functional  activity.  The  last,  spasmotoxin,  produces  severe  clonic 
and  tonic  spasms,  which  prostrate  the  animal  at  once.  Besides  meat- 
emulsion,  the  contused  brain-substance  from  horses  and  cattle  was  used; 
also  cows'  milk  mixed  with  carbonate  of  lime.  It  seems  that  the  culture- 
substance  determined,  to  a  certain  extent,  the  kind  of  toxin  which  was 
produced;  thus,  in  cultures  grown  in  brain-substance,  besides  the  tetanin, 
tetanotoxin  was  found  in  greatest  abundance;  old  cultures,  in  which  the 
tetanus  bacilli  were  dead,  produced  none  of  these  toxic  substances. 

The  same  author  has  also  been  successful  in  isolating  tetanin  from 
the  amputated  arm  of  a  patient  the  subject  of  tetanus.  The  disease  had 
developed  a  few  days  after  a  severe  crushing  injury  of  the  hand  and  fore- 
arm. The  first  symptoms  manifested  themselves  in  the  morning,  and  at 
12  o'clock  (noon)  the  operation  was  performed;  at  5  o'clock  on  the 
same  day  the  patient  expired  suddenly  during  one  of  the  tetanic  convulsions. 
The  bacilli  of  tetanus  were  found  in  the  serum  taken  from  the  cedematous 
portion  of  the  forearm,  in  connection  with  other  bacilli  of  different  length: 
staphylococci  and  streptococci.     Serum  containing  these  microbes  injected 


BACTEEIOLOGICAL    STUDIES.  445 

under  the  skin  of  mice^  guinea-pigs,  and  rabbits  invariably  produced  tetanus. 
On  the  other  hand,  a  dog  treated  in  the  same  manner,  as  well  as  after  in- 
jections of  tetanin,  remained  well.  A  horse  inoculated  with  a  culture  of 
bacilli  in  meat-emulsion  showed  no  symptoms  of  tetanus,  but  an  abscess 
formed  at  the  point  of  inoculation.  The  infiltrated  tissues  of  the  amputated 
arm  planted  on  sterilized  meat-emulsion,  solid  blood-serum,  and  emulsion 
made  of  the  flesh  of  fish,  yielded,  besides  ammonia,  only  tetanin;  no  trace 
of  tetanotoxin,  spasmotoxin,  nor  the  unnamed  toxin  which  could  be  obtained 
from  Eosenbach's  bacillus.  A  moderate  dose  of  tetanin  injected  into  the 
subcutaneous  tissue  of  a  horse  produced  muscular  contractions  which  lasted 
for  a  considerable  length  of  time,  but  the  characteristic  symptoms  of  tetanus, 
as  witnessed  in  horses  sufi^ering  from  tetanus,  did  not  appear. 

Pestana  obtained  the  toxin  of  the  tetanus  bacillus  from  a  pure  culture 
in  bouillon  in  the  absence  of  air,  which  was  preserved  at  a  temperature 
of  38°  C.  for  nineteen  days,  and  was  then  filtered  through  a  porcelain 
filter.  Careful  examination  of  the  filtrate  showed  that  it  contained  no 
bacilli.  Experiments  were  made  on  guinea-pigs  and  mice;  the  guinea- 
pigs  were  used  for  the  direct  injection  of  the  toxin  obtained  from  the 
cultures;  the  mice  were  employed  to  determine  the  toxicity  of  the  blood 
and  different  organs  of  the  guinea-pigs  which  received  the  filtrate.  One 
drop  of  toxin  injected  under  the  skin  of  the  thigh  of  a  guinea-pig  caused 
tetanus  at  the  end  of  twelve  hours  and  death  in  twenty-four  hours.  One- 
twentieth  of  a  drop  produced  in  mice  all  the  symptoms  of  the  disease  in 
eighteen  hours  and  death  in  thirty-eight  hours.  In  order  to  study  the 
diffusion  of  the  toxin  in  the  body  inoculations  were  made  at  variable 
periods  after  injection  of  the  toxin  and  with  the  blood  and  different  organs 
of  the  infected  animal.  In  the  first  series  of  experiments  7  drops  of  toxin 
were  injected  under  the  skin  in  the  sacral  region  of  a  guinea-pig.  As  soon 
as  symptoms  of'  tetanus  showed  themselves-  the  animal  was  killed  by 
cutting  the  carotid.  The  blood  obtained  was  injected  in  different  quan- 
tities under  the  skin  of  a  number  of  mice.  A  trituration  of  the  different 
internal  organs  and  muscles,  each  made  separately  and  diluted  with  a 
saline  solution,  was  injected  in  another  set  of  mice.  Tetanus  and  death 
were  uniformly  produced  in  the  mice  injected  with  15  or  more  drops  of 
blood,  and  also  in  those  which  had  been  inoculated  with  the  emulsion  of 
the  muscles  from  the  region  of  injection.  The  other  animals  remained  in 
perfect  health.  In  the  second  series  the  guinea-pig  was  killed  in  a  similar 
manner  after  the  tetanic  convulsions  had  become  general.  One  cubic 
centimetre  of  blood  and  half  this  quantity  of  the  emulsion  of  a  small  por- 
tion of  the  liver  produced  tetanus,  causing  death  of  the  mice  at  the  end 
of  forty-eight  hours  with  all  the  symptoms  of  the  disease.  The  tritura- 
tions prepared  from  the  other  organs  and  tissues  produced  no  effect  except 


446  PEINCIPLES    OF    SUKGERY. 

that  from  the  muscles  of  the  region  injected,  which  always  gave  positive 
results.  In  the  third  set  of  experiments  the  injections  were  made  after 
the  death  of  the  guinea-pig  with  emulsions  of  the  organs,  of  the  blood, 
and  of  clots  found  in  the  heart,  and  in  these  only  the  liver  contained 
enough  toxin  to  produce  tetanus.  These  experiments  tend  to  prove  that 
the  toxin  rapidly  enters  the  blood,  and  that  later  it  accumulates  in  the 
lungs,  spleen,  kidney,  but  principally  the  liver,  and  that  it  is  not  elimi- 
nated to  any  appreciable  extent  by  the  urine.  ISTotwithstanding  the  strik- 
ing predominance  of  neuro-muscular  phenomena  in  tetanus,  the  presence 
of  toxin  in  nervous  and  muscular  tissue  cannot  be  shown;  all  the  experi- 
ments made  with  these  tissues  yielded  negative  results. 

ETIOLOGY. 

The  clinical  and  experimental  researches  just  quoted  demonstrate 
that  the  bacillus  tetani  is  found  in  the  wound-secretions,  the  tissues,  and, 
in  some  instances,  in  the  blood  of  tetanic  patients,  and  that  tetanus  in 
animals  can  be  produced  artificially  by  injections  of  wound-secretions  of 
tetanic  patients,  or  by  using  mixed  or  pure  cultures:  facts  which  have 
firmly  established  the  microbic  nature  of  the  disease.  The  essential  cause 
of  tetanus  is  the  bacillus  first  discovered  by  Nicolaier  in  earth,  and  by  Eosen- 
bach  in  the  wound-secretion  of  a  tetanic  patient. 

Period  of  Incubation. — The  period  of  incubation,  both  in  man  and  in 
animals,  appears  to  be  extremely  variable,  in  some  instances  lasting  only 
twenty-four  hours,  while  in  others  weeks  may  elapse  between  the  time  of 
infection  and  the  first  manifestations  of  the  disease.  This  may  depend 
on  one  of  three  things:  1.  The  number  of  bacilli  introduced  may  be  so 
small  that  a  much  longer  time  is  necessary  before  active  symptoms  are 
produced  than  if  a  larger  quantity  had  been  introduced,  as  Watson  Cheyne 
has  shown  that  in  animals  the  injection  of  a  limited  number  of  the  bacilli 
of  tetanus  produced  no  symptoms.  2.  The  location  of  the  infection-atrium 
and  anatomical  characteristics  of  the  tissues  surrounding  it  may  influence 
the  time  which  is  necessary  to  develop  the  disease.  3.  Brieger's  investiga- 
tions have  shown  that  tetanic  convulsions  in  animals  are  produced  by  in- 
jections of  tetanin, — one  of  the  toxic  substances  derived  from  cultures 
of  the  bacillus  of  tetanus;  and  it  is  more  than  probable  that  the  active 
symptoms  of  tetanus  in  man  are  due  not  to  the  presence  in  the  tissues  of 
the  bacillus,  but  to  the  toxic  action  of  the  toxins  on  the  spinal  cord;  so 
that  the  duration  of  the  period  of  incubation  is  further  modified  by  the 
capacity  of  the  infected  tissues  to  yield  the  different  toxins.  The  degree 
of  virulence  of  the  bacillus  of  tetanus  must  certainly  play  an  important 
part,  not  only  in  determining  the  duration  of  the  incubation-stage,  but 
also  the  gravity  of  the  disease. 


ETIOLOGY.  447 

Specific  Microbic  Cause. — There  can  be  no  doubt  that  both  the  acute 
and  chronic  forms  of  tetanus  are  caused  by  the  same  microbe,  and  that  the 
clinical  difference  depends  upon  the  degree  of  virulence  of  the  primary 
cause  on  the  one  hand,  and  the  degree  of  susceptibility  of  the  individuals 
to  tetanic  infection,  on  the  other. 

In  reference  to  the  susceptibility  to  infection  with  the  bacillus  of 
tetanus,  it  has  been  shown  by  reliable  statistics  that  the  colored  races, 
under  the  same  conditions,  are  attacked  more  frequently  by  tetanus  than 
the  Caucasians.  Inoculation  experiments  have  shown  that  the  greatest 
difference  exists  among  different  kinds  of  animals  in  this  respect,  and 
there  is  no  reason  why  the  same  difference  of  susceptibility  to  this  disease 
should  not  exist  in  the  human  species.  As  the  natural  habitat  of  the 
bacillus  of  tetanus  is  the  soil,  we  can  readily  understand  that  the  disease 
should  occur  more  frequently  in  some  localities  than  in  others,  and  why 
it  is  more  prevalent  in  southern  than  northern  climates.  The  excretions 
and  cadavers  of  tetanic  animals  may  infect  the  soil,  where,  under  favor- 
able conditions,  the  bacillus  may  multiply,  and  in  this  manner  a  greater 
or  less  portion  of  the  surface  soil  becomes  a  nutrient  medium,  in  which 
an  immense  cultiire  is  developed  from  which  new  cases  can  become  in- 
fected. A  warm  climate  is  more  favorable  for  the  unlimited  reproduction 
of  the  bacillus  in  the  soil  than  northern  countries;  hence  the  greater 
prevalence  of  this  disease  in  the  tropics. 

Infection-atrium.— As  the  bacillus  of  tetanus  is  the  essential  cause 
of  the  disease,  the  remaining  causes  are  accidental  conditions,  which  result 
in  the  formation  of  an  infection-atrium.  We  liave  no  reliable  evidence  that 
the  hacillus  can,  enter  the  tissues  through  an  intact  mucous  membrane  or  un- 
hroJcen  shin.  Idiopathic  tetanus,  so  called,  is  a  clinical  form  of  tetanus 
where  even  the  most  thorough  examination  reveals  no  infection-atrium. 
As  in  cases  of  erysipelas,  under  similar  circumstances,  the  local  lesion  may 
have  been  so  insignificant  as  not  to  have  attracted  the  patient's  attention, 
or,  if  he  was  cognizant  of  it  at  the  time,  it  may  have  completely  disap- 
peared at  the  time  the  first  symptoms  developed  themselves. 

In  trismus  sive  tetanus  neonatorum  infection  undoubtedly  takes  place 
through  the  umbilicus.  In  a  case  of  this  kind  Beumer  found  the  tetanus 
bacillus  in  the  tissues.  There  is  hardly  an  operation,  capital  and  minor, 
which  has  not  furnished  its  quota  to  the  long  list  of  tetanic  patients.  It 
has  been  observed  most  frequently  after  amputation,  castration,  and  ex- 
tirpation of  the  thyroid  gland. 

"Weiss  reported  13  cases  of  tetanus  occurring  after  extirpation  of  the 
thyroid  gland.  He  attributes  the  frequency  with  which  this  disease  follows 
the  removal  of  this  organ  to  irritation  of  peripheral  nerves  induced  by  the 
numerous  ligatures.    Middeldorpf  observed  paralysis  of  the  facial  nerve  in 


448  PEINCIPLES    OF    SURGEEY. 

some  of  these  cases:  a  circumstance  which  would  indicate  a  central  origin 
of  the  disease.  In  53  total  extirpations  of  the  thyroid  gland  for  goitre 
made  by  Billroth,  tetanus  followed  in  12  cases,  while  no  cases  occurred 
in  109  partial  operations.  Two  cases  became  chronic,  in  which  the  disease, 
at  the  time  von  Eiselsberg  made  the  report,  had  lasted  for  six  and  nine 
years.  In  7  cases  there  was,  besides  the  ordinary  characteristic  symptoms, 
an  involvement  of  the  muscles  of  the  face,  neck,  larynx,  diaphragm,  and 
abdomen;  so  that  dyspnoea  and  even  loss  of  consciousness  occurred.  In 
the  fatal  cases  the  duration  of  the  disease  was  from  three  to  thirty  days,  and 
in  1  case  seven  months. 

Quite  a  number  of  cases  have  been  reported  during  the  last  few  years 
where  tetanus  occurred  after  abdominal  section.  Tetanus  occurring  after  an 
operation  must  be  the  result  of  infection  through  the  operation  wound 
with  the  specific  bacillus,  which,  without  exception,  takes  place  by  contact. 
As  the  bacillus  of  tetanus  is  not  a  pyogenic  microbe,  it  is  not  necessary 
that  a  wound  through  which  infection  has  occurred  should  suppurate. 
When  suppuration  takes  place  it  is  in  consequence  of  a  mixed  infection. 
It  is  a  well-known  clinical  fact  that  punctured,  lacerated,  and  gunshot 
wounds  of  the  hands  and  feet  are  most  liable  to  be  followed  by  tetanus. 
Before  it  was  known  that  tetanus  is  a  microbic  disease,  the  frequency 
with  which  this  disease  complicated  such  injuries  was  explained  upon 
the  grou:nd  that  the  part  injured  was  abundantly  supplied  with  sen- 
sitive nerves,  and  that  the  irritation  caused  by  the  injury  provoked  the 
disease.  As  thousands  of  operations  upon  the  hands  and  feet  performed 
under  aseptic  precautions  have  not  resulted  in  a  single  instance  in  tetanus, 
this  explanation  is  no  longer  tenable.  The  antiseptic  treatment  of  wounds 
has  greatly  diminished  the  frequency  of  tetanus  as  a  complication  of  opera- 
tion wounds.  Experience  has  shown  that  the  same  treatment  which  pre- 
vents suppuration  and  other  wound-infective  diseases  has  also  diminished 
the  frequency  of  tetanus.  Wounds  of  the  hands  and  feet  are  so  often  fol- 
lowed by  tetanus,  because,  in  the  first  place,  the  implement  or  substance 
which  inflicts  the  wound  is  frequently  contaminated  with  infected  earth 
or  dust,  and,  in  the  second  place,  such  wounds  are  often  neglected  and 
exposed  to  subsequent  infection  from  the  same  sources;  and,  lastly,  in- 
fected foreign  bodies  are  often  allowed  to  remain  in  the  wound.  In  a 
number  of  instances  animals  were  successfully  infected  by  inserting 
under  the  skin  particles  of  foreign  bodies  removed  from  tetanic  patients. 
Wounds  of  the  hands  and  feet  are  no  more  liable  to  cause  tetanus  than  wounds 
in  any  <other  part  of  the  lody  provided  they  are  not  exposed  to  greater  risTc  of 
infection.  Infection  through  the  uterus  after  abortion  and  during  child- 
bed has  been  repeatedly  observed. 

Gautier  has  collected  74  cases  of  tetanus,  36  following  abortion  and 


SYMPTOMS   AND    DIAGNOSIS.  449 

38  following  confinement.  Autopsies  were  made  in  15  cases;  3  presented, 
on  microscopical  examination  of  the  brain  and  cord,  no  appreciable  lesion; 
in  1  case  a  retained  putrefied  placenta  was  found  in  the  uterus;  in  5  sup- 
purative metritis  or  salpingitis;  in  1  ovarian  cyst.  The  other  autopsies 
showed  hypergemia  of  brain,  cord,  and  meningitis;  in  1  haemorrhage  into 
the  lateral  ventricles.  Ten  patients  recovered:  5  after  abortion,  5  after 
labor. 

Frost  gangrene  is  especially  prone  to  be  followed  by  tetanus.  Of  375 
cases  of  tetanus  collected  by  Thamhayn,  the  disease  followed  wounds  of 
the  fingers  and  hand  in  27  per  cent.;  of  the  thigh  and  leg,  25  per  cent.;  of 
the  toes  and  foot,  22  per  cent.;  of  the  head,  face,  and  neck,  11  per  cent.; 
of  the  arm  and  forearm,  8  per  cent.;  and  of  the  trunk,  6  per  cent.  Of  700 
cases  collected  by  the  same  author,  the  disease  was  known  to  have  followed 
a  trauma  in  603.  As  males  are  more  frequently  exposed  to  injury  than 
females,  the  disease  is  correspondingly  more  frequent  in  that  sex.  The 
largest  number  of  tetanic  patients  are  found  among  persons  from  10  to  30 
years  of  age,  although  no  age  is  entirely  exempt.  According  to  Larrey, 
CuUen,  and  Dupuytren,  the  disease  is  always  aggravated  by  drafts  of  cold 
air.  That  the  disease  is  never  caused  by  exposure  to  cold  requires  no  argu- 
ment; that  drafts  of  cold  air  aggravate  the  disease  when  it  exists  is  unques- 
tionable, as  every  peripheral  irritation  cannot  fail  in  aggravating  the  mus- 
cular spasms. 

SYMPTOMS   AND    DIAGNOSIS. 

The  toxins  of  the  bacillus  of  tetanus  act  upon  the  brain  and  the  spinal 
cord  in  a  somew^hat  similar  manner  as  strychnine.  If  the  spinal  cord  is  in- 
jured strychnia  acts  only  upon  the  parts  supplied  with  nerves  from  the 
intact  portion  of  the  cord.  If  the  posterior  roots  of  the  spinal  nerves  are 
divided  it  produces  no  spasms  in  toxic  doses.  If  in  an  animal  the  brain 
and  medulla  oblongata  are  removed  the  efi^ect  of  strychnia  upon  the  mus- 
cles is  not  impaired.  Injection  of  hydrate  of  chloral  arrests  the  spasm  pro- 
duced by  strychnia,  and,  consequently,  chloral  must  be  considered  as  the 
most  efficient  antidote  to  strychnia.  Even  the  most  acute  cases  of  tetanus 
begin  insidiously.  The  patient,  perhaps,  complains  of  a  sensation  of  chilli- 
ness and  a  feeling  of  soreness  about  the  region  of  the  neck,  and  shooting 
pains  and  stiffness  in  particular  muscular  groups.  The  first  symptom  which 
announces  the  onset  of  this  dreadful  disease  is  difficulty  in  mastication.  The 
patient  discovers,  accidentally,  that  he  is  unable  to  open  the  mouth  suffi- 
ciently to  drink  or  grasp  the  food.  On  inspection  nothing  abnormal  is 
found,  but  on  trying  to  separate  the  teeth  the  masseter  muscle  on  each  side 
becomes  rigid  and  prominent.  This  spasm  of  the  muscles  of  mastication  is 
called  trismus.    It  is  the  first  group  of  muscles  affected  by  the  central  lesion 


450  PRINCIPLES    OP    SUEGERY. 

produced  by  the  toxins  of  the  tetanus  bacillus.  If  other  causes  of  this  con- 
dition, such  as  inflammatory  lesions  in  the  pharynx  and  the  alveoli  of  the 
maxillary  bones,  can  be  excluded,  the  existence  of  trismus  is  almost  a  pathog- 
nomonic symptom  of  tetanus.  The  patient  next  complains  of  difficulty  in 
swallowing,  as  the  muscles  of  deglutition  become  afi:ected.  The  next  mus- 
cular groups  to  become  involved  are  the  muscles  back  of  the  neck  and  the  ex- 
tensors of  the  spine,  giving  rise  to  retraction  and  fixation  of  the  head  and 
overextension  of  the  spine:  conditions  which,  when  well  developed,  produce 
what  is  called  ^opisthotonos.  In  well-marked  opisthotonos  the  body  rests  on 
the  occiput  and  heels  when  the  patient  is  in  the  dorsal  position.  If  the  body 
is  bent  in  an  opposite  direction,  from  contraction  and  rigidity  of  the  ante- 
rior pectoral  and  abdominal  muscles,  the  condition  is  called  emprosthotonos. 
Contraction  of  muscles  on  the  side  of  the  chest  and  abdomen  gives  rise  to 
pUurosthotonos.  Orthotonos  means  tonic  spasm  and  rigidity  of  all  the  volun- 
tary muscles:  a  condition  frequently  present  in  advanced  cases  of  tetanus. 
The  face  of  tetanic  patients  presents  a  characteristic  mask-like  appearance 
from  the  contraction  and  rigidity  of  the  facial  muscles.  The  muscular 
spasms  are  clonic,  and  are  always  aggravated  by  the  slightest  causes,  as  walk- 
ing in  the  room;  touching  the  bedclothes  or  the  body  of  the  patient;  drafts 
of  air;  sudden,  unexpected  noises.  The  affected  muscles  are  rigid  from 
tonic  contraction,  but  this  state  of  rigidity  is  increased  by  the  paroxysmal 
clonic  spasms. 

In  acute  cases  the  temperature  soon  rises  to  40°  to  41°  C,  and  the 
pulse  is  correspondingly  increased  in  frequency.  The  temperature  curve 
shows  but  little  change  during  twenty-four  hours.  The  sensorium  usu- 
ally remains  unaffected  throughout  the  entire  course  of  the  disease.  As  the 
patient  finds  it  difficult  to  clear  the  mouth,  the  profuse  salivary  secretion 
escapes  from  the  mouth.  Eespiration  is  impeded  in  proportion  to  the  num- 
ber of  the  respiratory  muscles  affected.  In  severe  cases  early  dyspnoea  and 
cyanosis  are  present.  Special  senses  remain  intact.  The  pain  is  most  ex- 
cruciating, extending  from  the  neck  and  back  in  the  direction  of  the  nerves, 
leading  to  the  affected  muscular  groups.  The  pain  is  always  aggravated  with 
the  increased  convulsive  movements,  resulting  from  the  action  of  external 
irritants. 

In  consequence  of  deficient  food-supply,  the  intense  pain,  and  loss  of 
sleep,  rapid  emaciation  and  loss  of  strength  appear  as  early  and  constant 
symptoms.  Approaching  exhaustion  is  announced  by  profuse  clammy  per- 
spiration, coldness  of  the  extremities,  and  a  rapid,  feeble,  and  intermittent 
pulse.  As  soon  as  the  intercostal  muscles  are  affected  respiration  becomes 
more  and  more  embarrassed,  and  when,  finally,  the  diaphragm  is  thrown  into 
a  tonic  spasm  respirations  and  pulse  cease,  general  cyanosis  follows,  and 
death  may  ensue  during  the  first  spasm  of  the  diaphragm.     Should,  how- 


CLIN"IOAL    FOEMS    OP   TETANUS.  451 

ever,  the  patient  rally  from  this  attack,  he  will  be  almost  certain  to  succumb 
to  the  second  or  third  attack. 

Wunderlich  has  seen  the  temperature  shortly  before  death  rise  to  43° 
or  43°  C,  and  the  same  has  been  observed  in  animals  dying  from  tetanus 
by  Billroth,  Tick,  and  Leyden.  A  post-mortem  rise  in  temperature  to  44.7° 
G.  has  been  recorded  by  Wunderlich,  and  he  attributed  this  strange  phe- 
nomenon to  paralysis  of  the  central  heat-moderators.  In  chronic  tetanus 
the  disease  commences  very  insidiously,  and  the  graver  symptoms,  such  as  a 
very  high  temperature,  feeble  and  intermittent  pulse,  spasm  of  the  inter- 
costal muscle  and  diaphragm,  are  absent.  The  temperature  is  normal  or 
only  slightly  elevated.  Trismus  is  always  present,  to  which  may  be  added 
spasm  and  rigidity  of  the  muscles  of  the  back  of  the  neck  and  the  extensors 
of  the  spine.  The  trismus  makes  it  difficult  to  administer  food  in  sufficient 
quantity,  and,  on  this  account,  progressive  emaciation  is  one  of  the  promi- 
nent features  of  this  form  of  tetanus,  as  the  disease,  as  a  rule,  lasts  from 
six  to  ten  weeks.  The  disappearance  of  symptoms  is  as  gradual  as  their 
onset.  In  the  differential  diagnosis  it  is  important  to  distinguish  between 
tetanus  and  strychnia  poisoning,  hysteria,  catalepsy,  hydrophobia,  cerebro- 
spinal meningitis,  and  basilar  meningitis.  With  few  exceptions  it  is  pos- 
sible in  tetanus  to  establish  the  fact  of  infection,  and  the  clinical  history 
shows  that  different  muscular  groups  become  involved  successively  in  regu- 
lar order,  first  trismus,  then  rigidity  of  the  muscles  at  the  back  of  the  neck, 
and,  finally,  opisthotonos.  In  acute  cases  the  disease  is  attended  by  a  con- 
tinuously high  temperature.  In  strychnia  poisoning  the  maximum  symp- 
toms, opisthotonos  or  orthotonos,  are  developed  suddenly,  as  soon  as  a  toxic 
dose  of  the  drug  has  been  absorbed.  The  convulsive  movements  in  hysteria 
are  not  limited  to  any  definite  muscular  groups,  and  the  pulse  and  tempera- 
ture are  normal.  The  same  can  be  said  of  catalepsy.  In  hydrophobia,  as 
we  shall  see  subsequentl)^,  the  spasms  are  limited  to  the  muscles  of  degluti- 
tion, the  stage  of  incubation  is  longer  than  in  tetanus,  and  infection  is  al- 
ways caused  by  the  bite  of  a  rabid  animal,  usually  a  dog.  In  cerebro-spinal 
meningitis  muscular  spasm  and  rigidity  are  limited  to  the  extensor  muscles 
of  the  spine;  so  that,  even  if  the  disease  has  caused  well-marked  opisthotonos, 
trismus  is  absent.  Tubercular  meningitis  is  usually  ushered  in  by  intense 
headache,  vomiting,  and  photophobia,  and  if  tonic  muscular  spasms  set  in 
they  affect  the  muscles  at  the  back  of  the  neck  almost  exclusively.  Trismus 
is  never  present. 

CLINICAL    FORMS    OF    TETANUS. 

Acute  Tetanus. — The  stage  of  incubation,  as  a  rule,  is  shorter  than  that 
which  precedes  the  chronic  form  of  the  disease.  Trismus  develops  grad- 
ually, but  after  it  has  once  been  established  the  extension  of  the  disease  to 
other  muscular  groups  is  rapid.    A  high  temperature  and  rapid,  feeble  pulse 


453  PKINCIPLES    OF    SUEGEEY. 

are  always  present.  Eespiration  is  mechanically  embarrassed  by  the  suc- 
cessive implication  of  the  different  muscular  groups  which  are  concerned 
in  the  function  of  respiration,  the  last  one  to  become  affected  being  the 
diaphragm.  The  disease  may  prove  fatal  in  twenty-four  hours,  and  the  dura- 
tion is  seldom  prolonged  for  more  than  a  week. 

Chronic  Tetanus. — The  disease  not  only  commences  insidiously,  but  the 
symptoms  appear  gradually  and  never  develop  to  the  same  extent  as  in  acute 
tetanus.  The  most  marked  feature  is  trismus,  which  may  be  followed  by  a 
mild  degree  of  opisthotonos.  The  muscles  of  respiration  are  not  implicated, 
and  if  death  result  it  is  from  marasmus  and  exhaustion  and  not  from  apnoea. 
The  duration  of  the  disease  is  seldom  less  than  six,  nor  more  than  ten,  .weeks. 

Trismus. — Tetanus  in  which  only  the  muscles  of  mastication  are  affected 
is  called  trismus.  With  the  exception  of  the  infantile  form,  trismus  is  a 
chronic  and  comparatively  benign  affection. 

Tetanus  Neonatorum. — Tetanus  occu.rring  in  infants  during  the  first 
week  after  birth  is  clinically  characterized  as  trismus,  and  proves  fatal,  al- 
most without  exception,  in  a  few  days.  Infection  takes  place  through  the 
umbilicus  before  or  after  separation  of  the  cord.  It  is  a  disease  that  occurs 
much  more  frequently  in  tropical  than  northern  climates,  for  reasons  which 
have  been  heretofore  explained. 

Tetanus  Hydrophobicus,  or  Head  Tetanus. — -This  is  a  form  of  tetanus 
which  was  first  described  by  Bernard  and  Lepine  and  E.  Eose,  in  1870.  In 
the  cases  which  have  been  reported  it  followed  head  injuries,  especially 
wounds  of  the  face.  Besides  trismus,  it  is  characterized  by  paralysis  of  the 
facial  nerve  on  the  injured  side.  Brunner  maintains  that  paralysis  of  the 
facial  nerve,  which  seems  to  be  a  very  common  symptom  on  the  side  of  the 
lesion  in  man,  does  not  occur  in  experimental  tetanus  in  the  lower  animals; 
on  the  contrary,  there  is  in  them  invariably  facial  spasm.  From  his  analysis 
of  these  results  and  his  study  of  the  recorded  cases  in  man  Brunner  comes 
to  the  conclusion  that  in  many  cases  the  facial  paralysis  reported  must  be  the 
result  of  faulty  observation  or  else  an  accidental  complication  not  essentially 
belonging  to  this  form  of  tetanus.  He  produced  typical  tetanus  by  injecting 
subcutaneously  blood  from  the  longitudinal  sinus  and  fluid  taken  from  the 
pleural  and  pericardial  cavity  of  a  patient  who  had  died  of  tetanus  hydro- 
phobicus. During  deglutition  the  muscles  which  are  concerned  in  this  act 
are  thrown  into  spasm,  and  on  this  account  the  disease  bears  a  strong  resem- 
blance to  hydrophobia.  Klemm  collected  24  cases  of  this  disease.  Most  of 
them  recovered,  and  in  those  that  died  the  disease  passed  into  the  typical 
form  of  tetanus. 

PEOGNOSIS. 

The  most  important  element  in  prognosis  is  the  type  of  the  disease. 
The  more  acute  the  onset  and  the  more  intense  the  symptoms,  the  greater 


PATHOLOGY    AND    MORBID    ANATOMY.  453 

the  immediate  danger  to  life.  If  death  does  not  occur  within  two  weeks  the 
prospects  of  an  ultimate  recovery  are  good.  Of  280  cases  which  comprise  the 
Calcutta  statistics  of  this  disease,  75  per  cent,  proved  fatal.  This  list  repre- 
sents about  the  average  mortality  of  this  disease.  The  greater  the  excita- 
bility of  the  motor  centres  of  the  spinal  cord,  and  the  more  rapid  the  suc- 
cessive involvement  of  different  muscular  groups,  the  greater  the  danger  of 
an  early  dissolution.  In  acute  cases  death  is  always  preceded  by  great 
dyspnoea,  and  death  usually  occurs  during  an  attack  of  convulsions,  in  which 
the  intercostal  muscles  and  the  diaphragm  take  part.  Chronic  cases  ter- 
minate, as  a  rule,  in  recovery  after  an  illness  lasting  from  six  to  ten  weeks. 

PATHOLOGY   AND    MORBID    ANATOMY. 

The  absence  of  gross  pathological  changes  is  characteristic  of  tetanus. 
The  only  constant  lesion  found  is  an  hypergemic  condition  of  the  medulla 
oblongata  and  the  spinal  cord,  to  which  special  attention  has  been  called  by 
Leyden,  Jeffrey,  Eanvier,  and  Eobin.  As  all  of  the  peripheral  manifesta- 
tions of  the  central  lesion  point  to  an  increased  excitability  of  the  nervous 
centre,  w^e  would  expect  that  the  principal  lesions  are  to  be  found  in  the 
gray  substance  of  the  cord.  In  1857  Eokitansky  described  tetanus  as  an 
ascending  neuritis.  He  found  a  connective-tissue  proliferation,  in  the  form 
of  a  semifluid,  adhesive,  grayish  substance,  between  the  medullary  ele- 
ments of  the  nerves  leading  from  the  infected  district.  In  some  cases  he 
found  extensive  destruction  of  the  nerve-tubes,  and  their  space  occupied 
by  the  products  of  granular  degeneration:    colloid  and  amyloid  corpuscles. 

Lockhart-Clark  and  Dickinson  found,  as  the  most  constant  pathological 
lesion,  inflammatory  softening  of  the  gray  substance  of  the  cord  and  dilata- 
tion of  the  vessels.  Michaud  and  Benedict  found  cell-proliferation  into  the 
anterior  cornua  of  the  cord  and  great  vascularity.  Elischer  regarded  the 
central  lesion  as  a  myelitis  with  vacuolation'  in  the  ganglia-cells.  Tyson 
found  in  two  cases  destruction  of  the  central  canal  of  the  cord,  with  disin- 
tegration of  the  posterior  cornua.  Aufrecht  narrowed  the  morbid  anatomy 
of  tetanus  down  to  atrophy  of  the  anterior  horns,  in  the  cervical  portion  of 
the  spinal  cord.  Schultze  was  never  able  to  discover  any  evidences  of  mye- 
litis. The  hypergemia  of  the  cord,  which  is  so  constantly  found,  may  be  the 
result  of  a  passive  congestion;  at  present  this  cannpt  be  accepted  as  proof 
of  inflammation,  because  in  most  cases  the  anatomical  and  clinical  evi- 
dences do  not  sustain  this  supposition.  The  view  that  tetanus  is  essentially 
an  ascending  neuritis,  as  was  claimed  by  Eokitansky,  is  no  longer  tenable, 
since  it  is  not  supported  by  the  results  of  recent  investigations.  Minute 
tissue-changes  were  found  most  constantly  in  the  spinal  cord.  Punctiform 
haemorrhages  in  the  gray  substance  of  the  cord  are  seen  frequently,  more 
especially  in  the  anterior  horns.     The  chromophilic  elements  of  the  nerve- 


454  PRINCIPLES    OF    SUEGERY. 

cells  are  smaller  and  altered  in  shape,  in  some  places  they  are  transformed 
into  granules  scattered  through  the  protoplasm  of  the  cell.  In  some  prep- 
arations these  elements  had  disappeared  at  the  periphery  of  the  cells,  as  has 
also  been  observed  in  hydrophobia  and  in  ansemia  of  the  cord  from  com- 
pression of  the  abdominal  aorta.  The  achromatic  substance  is  deeper  in 
color.  In  the  earlier  stage  of  the  disease  the  nuclei  are  not  much  affected, 
but  later  their  interior  is  less  distinct,  the  coloration  more  intense,  and  the 
nuclear  net-work  obscure.  The  neuroglia-cells  are  increased  in  size.  In  the 
later  stages  the  degenerative  changes  extend  to  the  white  substance  of  the 
cord.  It  is  left  for  future  research  to  furnish  more  reliable  information  con- 
cerning the  pathology  and  morbid  anatomy  of  tetanus.  At  present  we  can 
only  surmise  that  the  toxins  of  the  bacillus  act  upon  the  gray  matter  of  the 
cord,  where  minute  lesions  are  produced,  which  must  account  for  the  clinical 
manifestations  of  the  disease. 

TREATMENT. 

The  prophylactic  treatment  of  tetanus  has  in  view  the  prevention  of 
infection  by  the  usual  antiseptic  precautions  in  the  treatment  of  wounds 
and  local  lesions  which  might  become  the  necessary 'infection-atrium.  As 
tetanus  follows  more  frequently  injuries  insignificant  in  themselves  than 
large  wounds  or  major  operations,  it  behooves  the  surgeon  to  treat  the 
minutest  lesions  with  the  greatest  care  and  in  strict  accordance  with  anti- 
septic principles.  Foreign  bodies  should  be  carefully  searched  for  and  re- 
moved. Even  the  most  recent  accidental  wounds  should  be  treated  as  in- 
fected wounds,  and  should  be  rendered  aseptic  by  a  thorough  primary  dis- 
infection. The  antiseptic  treatment  must  be  continued  until  the  wound  is 
completely  healed,  and  during  this  time  the  injured  part  must  be  kept  at 
rest.  Wounds  of  the  lower  extremities  must  be  treated  by  confining  the 
patient  to  bed,  and  wounds  of  the  upper  extremities  demand,  in  their  treat- 
ment, fixation  of  the  limb  upon  some  kind  of  a  splint  or,  at  least,  suspension 
in  a  sling. 

In  acute  cases  of  tetanus  the  most  that  can  be  expected  from  treatment 
is  palliation.  The  excruciating  pain  is  often  only  relieved  by  inhalation  of 
chloroform.  The  administration  of  chloroform  should  be  conducted  by  the 
physician  in  attendance  or  a  reliable  assistant,  and  should  only  be  carried 
to  the  extent  of  relaxing  the  contracted  muscles,  and  repeated  as  often  as 
necessary  to  procure  rest.  Morphia  in  doses  of  ^/ ^  to  ^/o  grain,  with  ^/oqo 
-grain  of  atropia,  should  be  given  hypodermically  every  three  or  four  hours 
until  the  desired  effect  is  reached.  In  less  severe  cases  the  internal  use  of 
hydrate  of  chloral  and  potassic  bromide,  each  in  doses  of  from  15  to  20 
grains,  can  be  given  every  three  or  four  hours  with  excellent  effect.  Woorara, 
which  has  been  quite  extensively  used  in  the  treatment  of  the  disease,  is 


TKEATMENT.  455 

absolutely  contraindicated,  as  its  paralytic  effect  on  the  heart  cannot  fail  in 
producing  anything  but  a  deleterious  effect. 

Fancel  and  Frache  report  a  case  of  tetanus  successfully  treated  by  hypo- 
dermic injections  of  carbolic  acid  after  the  usual  treatment  by  bromide  of 
potassium  and  hydrate  of  chloral  had  failed  to  ameliorate  the  symptoms. 
The  dose  consisted  of  1  centigramme  every  two  hours,  and  the  treatment 
was  continued  for  seventeen  days.  The  effect  was  almost  immediate,  the 
spasms  becoming  much  less  violent  and  less  painful  and  the  patient's  general 
condition  showing  marked  improvement.  The  authors  refer  to  the  intro- 
duction of  this  mode  of  treatment  by  Baccelli,  who  reported  a  case  in  which 
he  had  employed  it  successfully  in  1888.  They  do  not,  however,  agree  with 
him  in  attributing  the  efficacy  of  treatment  to  the  sedative  action  of  the 
carbolic  acid  on  the  spinal  centres,  but  regard  it  as  due  to  the  parasiticide 
power  of  the  remedy. 

Deep  injections  of  a  2-per-cent.  solution  of  carbolic  acid  in  the  course 
of  the  principal  nerves  is  the  method  employed.  Experience  has  shown 
that  tetanic  patients  are  very  tolerant  to  the  action  of  carbolic  acid,  and  yet 
care  is  required  not  to  carry  the  treatment  far  enough  to  endanger  the  life 
of  the  patient  by  drug  intoxication.  Ascoli  cites  35  cases  of  tetanus  treated 
by  parenchymatous  injections  of  carbolic  acid  with  only  1  death.  The 
initial  dose  is  about  3  grains  a  day,  which  is  rapidly  increased  to  6  or  8 
grains  a  day. 

The  following  remarks  on  the  treatment  of  tetanus  with  antitoxin  are 
taken  from  a  valuable  paper  on  this  subject  from  the  pen  of  E.  T.  Hewlett, 
published  in  The  Practitioner: — 

"The  method  of  preparing  the  tetanus  antitoxin  is  similar  to  that 
employed  in  obtaining  the  diphtheria  antitoxin.  In  practice  it  is  met  with 
in  at  least  three  forms:  (1)  the  blood-serum,  as  such  is  sometimes  used;  (2) 
the  dry  form,  1  gramme  of  the  dry  substance  corresponding  to  10  cubic 
centimetres  of  the  fluid  serum;  (3)  the  serum  may  be  precipitated  with 
alcohol  and  the  precipitate  dried, — Tizzoni's  antitoxin.  This  last  is,  per- 
haps, the  most  concentrated  form. 

"Dose  of  the  Antitoxin.^ — It  is  difficult  to  state  definitely  what  should 
be  the  dose,  for  this  has  varied  enormously  in  the  published  cases.  The 
smallest  dose  recorded  is  5  or  6  cubic  centimetres,  the  largest  167  cubic 
centimetres,  which  was  given  in  one  instance  by  Eoux;  and  it  is  remark- 
able that  this  enormous  amount  gave  rise  to  no  disturbance  except  urti- 
caria, which  is  also  a  frequent  phenomenon  with  the  diphtheria  antitoxin. 
Of  the  fluid  serum,  which  should  have  an  immunizing  power  of  at  least 
1,000,000,  I  should  be  inclined  to  recommend  20  to  40  cubic  centimetres 
for  the  first  dose,  followed  by  10  to  20  cubic  centimetres  every  six  or  twelve 
hours  afterward.     Of  the  dried  serum,  1  gramme  corresponds  to  10  cubic 


456  PEINCIPLES    OF    SURGERY. 

centimetres  of  the  fluid  serum,  and  equivalent  amounts  are  to  be  adminis- 
tered,— that  is,  2  to  4  grammes  for  the  first  dose,  followed  by  doses  of  1  to  2 
grammes;  while  Tizzoni  recommends  2.25  grammes  of  his  antitoxin  for  the 
first  dose  and  0.6  gramme  for  subsequent  doses.  The  amount  and  frequency 
of  the  injection  of  antitoxin  are  to  be  based  on  the  urgency  and  subsequent 
amelioration  or  otherwise  of  the  symptoms,  it  being  borne  in  mind  that,  the 
shorter  the  incubation  period,  the  more  acute  will  probably  be  the  course 
of  the  disease. 

"Administration  of  the  Dose. — The  serum  must  be  administered  en- 
tirely by  subcutaneous  injections.  The  syringe  should  be  a  large  one,  with 
the  capacity  of  at  least  10  cubic  centimetres,  an  ordinary-sized  hypodermic 
syringe  necessitating  multiple  punctures.  Before  using  the  syringe  it  should 
be  taken  to  pieces  and  sterilized,  and  the  skin  to  be  punctured  should  be  dis- 
infected with  l-to-20  carbolic  lotion.  If  the  fluid  serum  be  employed  the 
requisite  amount  should  be  poured  out  into  a  measure  previously  rinsed  with 
boiling  water  to  sterilize  it,  and  the  vial  quickly  corked  again  and  kept  in  a 
cool,  dark  place,  preferably  on  ice;  and  if,  after  being  opened  once  or  twice, 
it  becomes  cloudy  from  the  presence  of  bacteria,  it  must  be  discarded.  The 
dried  serum  and  Tizzoni's  antitoxin  must  be  finely  powdered,  and  the  dose 
weighed  out  and  dissolved  in  5  or  10  parts  (according  to  convenience)  of 
distilled  water,  which  has  been  sterilized  by  boiling  for  ten  minutes.  As 
heat  is  fatal  to  the  antitoxin,  no  warmth  must  be  employed  to  hasten  solu- 
tion; and  syringes,  vessels,  etc.,  ought  to  be  allowed  to  cool  after  sterilization 
before  using.  The  antitoxin  is  injected  subcutaneously  into  loose  cellular 
tissue,  as  in  the  back  between  the  scapulas  or  in  the  abdomen. 

"Employment  of  the  Antitoxin  (a)  as  a  Remedy. — ^For  the  antitoxin 
to  have  a  fair  chance  it  ought  to  be  administered  as  soon  as  the  onset  of 
tetanus  is  probable.  Any  distinct  sign,  such  as  stiffness  of  the  neck,  diffi- 
culty in  opening  the  mouth,  or  even  considerable  pain  at  the  seat  of  injury 
or  radiating  from  it,  coming  on  a  few  days  after  the  accident  without  ap- 
parent cause,  should  at  once  lead  us  to  employ  this  remedy. 

"The  amount  of  antitoxin  necessary  for  cure  increases  very  rapidly  with 
the  duration  of  the  disease,  so  that  it  is  imperative  to  employ  the  remedy  as 
soon  as  possible. 

"(b)  As  a  Prophylactic. — The  wonderful  power  exerted  by  the  anti- 
toxin in  rendering  the  animal  body  proof  against  tetanus  suggests  whether 
it  might  not  be  wise  in  some  instances  to  use  it  before  the  disease  declares 
itself.  For  example,  a  person  sustains  a  lacerated  wound  which  is  freely 
soiled  with  the  earth;  it  is  untreated  and  suppurates,  and  he  comes  under 
observation  only  when  matters  have  gone  from  bad  to  worse.  Here  the  onset 
of  tetanus  might  not  be  unlikely  later  on,  and  a  small  injection  of  antitoxin, 
judging  by  the  result  of  experiment,  would  render  this  impossible.     The 


TEEATMENT.  457 

amount  sufficient  to  immunize  is  much  smaller  than  is  required  to  cure,  and 
probably  an  injection  of  5  cubic  centimetres  of  serum  would  be  enough  for 
this  purpose." 

Kneass  has  collected  from  literature  68  cases  of  tetanus  treated  by  anti- 
toxin, of  which  61  are  available  for  statistical  purposes,  and  these  give  a 
mortality  only  slightly  less  than  under  the  older  methods  of  treatment. 
Eoux  has  never  seen  the  least  effect  of  the  serum  upon  the  course  of  the 
disease.  Lambert  believes  in  the  therapeutic  value  of  the  remedy,  and  agrees 
with  Tizzoni  that  it  does  not  act  by  neutralizing  the  active  principles  of  in- 
fection, but  by  immunizing  those  parts  of  the  body  not  already  tetanized, 
thus  limiting  the  tetanus  locally.  He  accepts  80  per  cent,  as  a  fair  state- 
ment of  the  fatality  in  tetanus.  With  Bazy,  ^ocard,  and  others,  he  is  in- 
clined to  advise  prophylactic  inoculations  in  the  treatment  of  wounds  liable 
to  give  rise  to  tetanus.  This  recommendation  is  based  especially  upon 
Eoux's  statement,  well  supported  by  experiment,  to  the  effect  that  the  toxin 
can  be  readily  neutralized  at  the  time  of  infection,  but  that  a  very  short 
time  afterward  it  requires  doses  thousands  and  hundreds  of  thousands  of 
times  larger  to  accomplish  the  same  effect. 

G-oldschneider  and  Flatau  found,  by  using  Mssl's  stain,  that  the  disin- 
tegration of  NissFs  chromatophilic  elements  took  place  within  a  very  short 
time  after  the  intoxication.  Tetanus  antitoxin  given  at  a  proper  time  after 
the  toxin  prevented  the  changes,  when  injected  after  the  production  of  the 
latter  it  was  capable  of  causing  restoration  of  the  ganglia-cells  to  normal. 

The  antidotal  effects  of  the  antitoxin  could  not  be  more  clearly  shown 
and  the  discoveries  appear  to  strengthen  the  view  of  the  Behring  school, 
that  toxin  and  antitoxin  neutralize  each  other. 

Metschnikoff  has  studied  the  influence  of  the  central  nervous  system 
■  on  tetanus  toxin,  and  confirms  the  results  of  Wassermann  and  Takalai.  The 
brain-tissue  of  the  guinea-pig  protects  several  times  the  fatal  dose  of  tetanus 
toxin. 

Tetanus  toxin  is  not  destroyed  by  mixing  it  with  brain-substance,  and 
the  value  of  the  latter  should  be  attributed  to  an  intervention  of  the  body 
of  the  inoculated  animal.  The  mixture  of  brain-substance  and  toxin  pro- 
duces considerable  inflammation  when  injected  into  the  tissues,  and  this 
reaction  attracts  leucocytes,  which  are  not  only  capable  of  destroying  mi- 
croorganisms, but  also  of  absorbing  toxic  substances. 

The  intracerebral  injection  of  antitoxin  in  the  treatment  of  tetanus  has 
been  warmly  recommended  by  Kocher.  This  method  of  treatment  was  j&rst 
suggested  by  Eoux  and  Borrel.  They  made  45  experiments  on  guinea-pigs. 
Tetanus  was  artificially  produced,  and  after  the  appearance  of  the  first 
symptoms  the  serum  was  injected  directly  into  the  brain  and  35  of  the  ani- 
mals recovered.    In  17  other  animals  treated  by  subcutaneous  injection  of 


458  PEINCIPLES    OF    SURGERY. 

the  antitoxin  in  much  larger  doses,  only  2  survived.  All  of  the  control 
animals  died.  The  combined  mortality  of  tetanus  treated  by  cerebral  in- 
jections up  to  the  present  time  is  about  52  per  cent.  It  is  doubtful  if  this 
treatment  will  receive  any  encouragement  in  the  future. 

All  patients  suffering  from  tetanus  should  be  kept  in  a  quiet,  dark 
room,  and  all  kinds  of  excitement  must  be  carefully  avoided,  as  bodily  and 
mental  rest  are  important  elements  in  the  treatment.  As  mastication  is  im- 
possible, the  patient  must  be  nourished  with  liquid  food,  which  he  can  sip 
through  an  elastic  tube.  If  swallowing  is  impossible,  a  small  elastic  tube 
is  introduced  through  one  of  the  nostrils  into  the  stomach,  and  food  is  ad- 
ministered at  regular  intervals  by  this  method.  In  chronic  tetanus  warm 
baths  are  grateful  to  the  patient,  and  exercise  a  decided  influence  in  amelio- 
rating the  symptoms.  The  surgical  treatment  of  tetanus  has  yielded  no 
better  results  than  the  internal  use  of  drugs.  In  all  cases  the  infection- 
atrium  should  be  carefully  examined,  and,  if  necessary,  the  wound  or  local 
lesion  should  be  thoroughly  disinfected,  as  this  treatment  may  be  the  means 
of  preventing  further  infection  from  this  source.  Scars  should  be  excised 
and  foreign  bodies  removed. 

Under  the  belief  that  tetanus  is  an  ascending  neuritis,  nerve-section,  or 
neurotomy,  has  been  practiced  for  the  purpose  of  preventing  further  exten- 
sion of  the  inflammation  by  interrupting  the  continuity  of  the  nerve;  but 
the  results,  as  could  be  expected,  were  disappointing,  and  the  operation  has 
fallen  into  well-deserved  desuetude.  When  nerve-stretching  was  the  rage 
in  the  treatment  of  all  kinds  of  nerve-affections  it  was  also  applied  in  the 
treatment  of  tetanus,  but  the  results  were  no  better  than  after  neurotomy. 
ISTocht  reported  24  eases  of  tetanus  treated  by  this  method,  and  of  this  num- 
ber only  4  recovered:  the  average  percentage  of  recoveries  in  all  cases  of 
tetanus  not  treated  by  surgical  resources.  Amputation  is  only  indicated  in' 
cases  where  the  local  conditions  which  give  rise  to  tetanus  make  it  necessary 
to  resort  to  this  operation  without  reference  to  the  existence  of  tetanus. 


CHAPTER  XVIII. 

Hydrophobia. 

Hydeophobia,  lyssa^  canine  madness,  and  rabies  are  synonymous  terms 
used  to  designate  a  nervous  disease  caused  by  the  bite  of  a  .rabid  dog  or 
other  animal,  attended  with  violent  spasms  if  the  patient  attempt  to  swallow 
water  or  other  liquids  and  by  embarrassment  of  respiration  from  spasm  of 
the  laryngeal  muscles.  This  disease  never  occurs  spontaneously  in  man,  but 
is  always  the  result  of  inoculation  with  the  virus  of  a  rabid  animal.  Al- 
though this  disease  never  originates  elsewhere  than  in  the  dog  and  animals 
belonging  to  the  same  species,  the  wolf,  fox,  and  jackal,  the  virus  of  rabies 
is  capable  of  being  communicated  to  all  warm-blooded  animals.  It  has  been 
estimated  that  in  man  the  disease  is  derived  in  nine  out  of  ten  cases  from 
dogs;  sometimes  it  is  contracted  from  cats,  and  sometimes,  but  very  rarely, 
from  foxes  or  wolves.  The  specific  virus  of  hydrophobia  appears  to  be  gen- 
erated in  the  glandular  appendages  of  the  mucous  membrane  of  the  mouth 
and  throat,  and  is  transmitted  by  the  saliva  of  the  rabid  animal.  For  this 
reason  it  has  been  observed  that  inoculation  is  more  apt  to  take  place  from 
a  bite  on  an  uncovered  part  of  the  body — as,  for  example,  on  the  hands  or 
face — than  from  a  bite  inflicted  through  the  clothes,  as  in  the  latter  case  the 
greater  portion  of  the  saliva  is  deposited  in  the  clothing.  Not  every  person 
bitten  by  a  rabid  dog  necessarily  contracts  the  disease,  as  statistics  have 
shown  that  about  one-third  of  the  animals  and  human  beings  bitten  by 
mad  dogs  escape  all  danger.  This  partial  immunity  is  explained  in  part  by 
the  virus  being  diluted,  and  being  wiped  from  the  teeth  of  the  rabid  animal 
by  clothing;  and  also  by  well-ascertained  facts  proving  the  absence  of  sus- 
ceptibility to  its  action  in  certain  individuals,  both  in  animals  and  in  man. 

Eenault's  careful  experiments  proved  that  one-fourth  of  the  inoculated 
creatures  escaped  the  effects  of  the  inoculations,  which  were  mortal  in  the 
other  three-fourths.  As  in  civilized  countries  the  disease  is  contracted 
almost  exclusively  from  rabid  dogs,  it  is  necessary  to  call  attention  to  the 
symptoms  which  characterize  the  disease  in  this  animal,  in  order  that  it  may 
be  recognized  in  time,  so  that  the  infected  animal  can  be  isolated  and  kept 
in  close  confinement  until  the  result  shall  prove  or  disprove  the  correctness 
of  the  diagnosis.  It  is  a  great  mistake  to  kill  an  animal  suspected  to  be  rabid, 
until  by  careful  observation  continued  for  some  length  of  time,  or  from  the 
result  of  the  disease,  a  positive  diagnosis  can  be  made,  and  thus  a  great  deal 
of  unnecessary  fear  may  be  avoided. 

(459) 


460  PEINCIPLES    OF    SUEGEEY. 

HYDEOPHOBIA    IN    THE    DOG. 

The  name  "hydrophobia,"  meaning  literally  a  dread  of  fluids,  is  a  proper 
designation  for  the  disease  as  it  occurs  in  man,  because  a  peculiar  dread  of 
fluids  is  the  most  characteristic  symptom  of  this  disease  in  the  human  being. 
This  symptom  does  not  exist  in  the  dog;  hence,  in  this  animal  we  should 
speak  of  the  disease  as  rabies,  in  man  as  hydrophobia.  Fleming,  who  is  an 
acknowledged  authority  on  everything  that  pertains  to  hydrophobia,  makes 
the  following  statement  in  reference  to  the  ability  of  rabid  animals  to  take 
fluids:  "The  many  hundreds  of  rabid  dogs  seen  by  Blaine,  Youatt,  and 
others  did  not  evince  any  marked  aversion  to  fluids.  On  the  contrary,  the 
rabid  animal  is  generally  thirsty,  and  if  water  be  offered  will  lap  it  up  with 
avidity,  and,  at  the  commencement  of  the  disease,  will  always  swallow  it. 
When,  at  a  later  period,  the  constriction  about  the  throat,  which  is  symptom- 
atic of  the  malady,  renders  swallowing  difficult,  the  animal  does  not  the  less 
endeavor  to  drink,  and  lappings  are  as  frequent  and  prolonged  as  deglutition 
is  retarded.  Even  then  we  see  the  suffering  creature,  in  despair,  plunge  its 
entire  muzzle  into  the  vessel,  and  gulp  at  the  water  as  if  determined  to  over- 
come the  spasmodic  closure  of  the  throat  by  forcing  down  the  fluid.  Tanta- 
lus did  not  experience  a  greater  torment  with  regard  to  water  than  does  the 
unlucky  dog."  The  excessive  sensibility  to  pain  and  the  action  of  the  mild- 
est external  irritants  so  characteristic  of  hydrophobia  in  the  human  being  are 
absent  in  the  rabid  dog.  The  animal  is  almost  insensible  to  pain;  he  will 
dash  himself  against  the  bars  of  his  kennel,  tear  them  when  his  mouth  is 
lacerated  and  bleeding,  and  he  has  been  known  to  seize  a  red-hot  poker  in 
his  mouth  and  hold  on  to  it,  apparently  unconscious  of  suffering.  Eabies  in 
the  dog  must  be  suspected  when  the  animal  becomes  dull,  morose,  mopes, 
and  avoids  his  master  and  companions.  During  the  commencement  of  the 
disease  the  animal  is  exceedingly  restless,  and  is  always  on  the  move,  prowl- 
ing, snapping,  and  barking  at  imaginary  objects.  During  the  first  two  or 
three  days  there  is  rarely  any  tendency  on  the  part  of  the  animal  to  bite,  nor 
to  paroxysms  of  uncontrollable  fury. 

The  danger  in  this  stage  to  man  and  other  animals  comes  from  licking 
rather  than  biting,  for  there  is  a  propensity  to  extraordinary  demonstrations 
of  affection.  After  a  time,  however,  a  paroxysm  of  maniacal  fury  comes  on, 
generally  provoked  by  the  sight  of  another  dog.  When  this  has  subsided  the 
animal  again  becomes  controllable,  but  manifests  a  strange  disposition  to 
wander  from  place  to  place.  He  is  now  most  dangerous.  With  a  slinking 
and  troubled  aspect,  his  head  and  tail  down,  his  eyes  suffused,  and  foam  at 
his  mouth,  he  walks  or  trots  along,  snapping  and  biting  at  real  and  imaginary 
objects.  He  is  only  aggressive  when  attacked,  and  then  his  fury  seems  un- 
bounded. When  tired  out  from  inadequate  nourishment  and  the  ceaseless 
wanderings,  he  drops  exhausted  in  some  out-of-the-way,  solitary  corner,  and. 


HYDROPHOBIA    A    MICROBIC    DISEASE.  461 

after  a  rest,  starts  of!  again  on  his  lonely  journey,  seemingly  impelled  by 
some  irresistible  force,  and  is  finally  killed  or  dies  of  exhaustion.  The  dura- 
tion of  the  disease  in  the  dog  never  exceeds  ten  days,  and  in  the  majority 
of  cases  the  animal  dies  on  the  fourth  or  the  sixth  day  after  the  appearance  of 
the  first  symptoms. 

From  a  study  of  the  symptoms  in  this  animal  we  can  readily  distinguish^ 
three  stages:  1.  Prodromal.  2.  Irritation.  3.  Paralytic.  During  the  pro- 
dromal stage  the  most  notable  changes  refer  to  the  altered  habits  of  the 
animal,  while  the  stage  of  irritation  culminates  in  attacks  of  ungovernable 
rage,  provoked  by  real  or  fancied  causes.  The  last,  or  paralytic,  stage  pre- 
cedes death,  which  takes  place  from  exhaustion.  The  period  of  incubation 
in  the  dog  is  variable;  it  is  usually  from  six  to  twelve  weeks,  but  may  extend 
to  a  much  longer  period.  Frank,  from  a  study  of  200  observed  cases  of  rabies 
in  the  dog,  found  that  the  average  period  of  incubation  was  three  months; 
the  extremes,  six  and  seven  days  and  eleven  months. 

HYDROPHOBIA   A   MICROBIC    DISEASE. 

The  microbic  cause  of  hydrophobia  remains  undiscovered  at  the  present 
time.  Bacteriologists  have  found  and  described  different  microbes  in  the 
tissues  of  hydrophobic  animals,  but  the  direct  relationship  between  any  of 
them  and  the  causation  of  this  disease  has  not  been  established.  That  the 
disease  is  of  a  microbic  origin  has  been  shown  abundantly  by  its  commu- 
nicability  and  the  artificial  production  of  the  disease  in  animals  by  inocula- 
tions with  spinal-cord  tissue  from  hydrophobic  animals. 

Eaynaud  and  Lannelongue  discovered  that  rabbits  could  be  successfully 
inoculated  with  saliva  from  rabid  animals.  Pasteur  corroborated  these  ob- 
servations by  his  own  experiments,  and  cultivated  from  the  blood  of  the  in- 
fected rabbits  in  veal-bouillon  a  microorganism  which  in  shape  resembled 
the  figure  8;  this  microbe  was  surrounded  by  an  envelope  of  a  gelatinous 
substance.  In  the  cultures  these  rods  are  said  to  have  become  converted  into 
chain  cocci.  Fowls  and  guinea-pigs  were  not  found  susceptible  to  inocula- 
tions with  cultures  of  this  microbe.  After  Pasteur  had  regarded  these  mi- 
croorganisms as  the  cause  of  hydrophobia,  he  produced  the  same  disease  in 
rabbits  by  inoculations  with  saliva  from  healthy  persons.  Yulpian  also  suc- 
ceeded in  producing,  by  inoculations  of  normal  saliva  in  rabbits,  a  disease 
which  proved  fatal  in  two  days;  and  with  a  small  quantity  of  blood  taken 
from  the  dead  animals  the  disease  could  be  communicated  to  other  rabbits. 
The  disease  thus  produced  was  probably  the  same  as  that  described  by  Stern- 
berg. This  observer  caused  marked  septicaemia  in  rabbits  by  injecting  sub- 
cutaneously  his  own  saliva  in  small  doses.  Injections  of  1.25  to  1.75  cubic 
centimetres,  with  few  exceptions,  caused  death,  usually  within  forty-eight 
hours.    The  constant  and  characteristic  lesion  found  was  a  diffuse  cellulitis. 


463  PEINCIPLES    OF    SUEGERT. 

or  inflammatory  oedema,  extending  in  all  directions  from  the  point  of  in- 
jection, attended  with  an  abundant  exudation  of  bloody  serum,  swarming 
with  micrococci.  Heemorrhagic  extravasations  in  the  connective  tissue,  and 
in  the  various  organs,  were  of  frequent  occurrence,  and  changes  in  the  liver 
and  spleen,  such  as  are  common  in  rapidly-fatal  septic  diseases,  were  gener- 
^  ally  found.  The  disease  could  be  communicated  by  dipping  an  hypodermic 
needle  into  the  blood  of  a  rabbit  just  dead  from  the  result  of  an  injection 
of  saliva;  inoculating  a  healthy  rabbit,  a  rapidly-fatal  septicaemia  was  pro- 
duced. 

Gibier  found,  in  the  brain  of  hydrophobic  animals,  round,  shining 
granules,  which  stained  slowly  and  imperfectly  in  aniline  dyes. 

Fol  stained  the  brain-substance,  according  to  Weigert's  method,  and 
discovered  in  the  hollow  spaces  of  the  neuroglia  groups  of  micrococci.  The 
same  microbe  he  found  also  in  the  nerve-fibres,  between  the  sheath  and  axis- 
cylinder.  Babes  stained  the  specimens  according  to  Gram's  method,  and 
found  cocci  in  the  cells,  especially  those  of  the  surface  of  the  brain.  The 
cocci  looked  like  diplococci,  and  were  always  found  aggregated  in  flat  clus- 
ters. Fol  and  Babes  claim  to  have  succeeded  in  obtaining  a  culture  of  the 
microbes  found  in  the  brain.  The  former  used  for  nutrient  medium  a  fil- 
trate of  triturated  brain  and  parenchyma  of  salivary  gland.  Of  8  dogs,  rats, 
and  rabbits  inoculated  with  the  first  culture,  5  died  of  well-marked  hydro- 
phobia; of  8  dogs  inoculated  with  the  second  culture,  4  died.  The  inocula- 
tions were  always  made  by  infecting  the  brain  through  an  opening  in  the 
skull.  The  microbes  in  the  cultures  corresponded  in  shape  and  size  with 
those  found  in  the  brain  of  hydrophobic  animals.  The  third  series  of  cult- 
ures produced  only  negative  results.  The  microbes  in  these  cultures  were 
more  readily  stained  than  most  of  the  first  two  cultures.  Babes  cultivated 
the  microbe  Upon  gelatin  and  coagulated  blood-serum,  to  which  was  added 
brain-substance  obtained  from  rabbits.  The  cultures  grew  slowly,  and  ap- 
]oeared  as  gray  spots.  Successful  inoculations  were  made  with  the  second 
and  third  generations. 

Spinello  and  Eivolta  have  recently  discovered  another  microorganism 
in  the  central  nervous  system  of  hydrophobic  animals.  It  is  a  small  bacillus 
and  Memino  believes  that  there  is  no  doubt  of  the  etiological  relationship 
between  this  organism  and  hydrophobia.  He  succeeded  in  cultivating  it  in 
artificial  nutrient  media  and  by  inoculations  with  a  pure  culture  reproduced 
the  disease  in  dogs  and  other  animals.  He  found  the  bacillus  in  the  cerebro- 
spinal fluid  in  the  substance  of  the  brain  and  spinal  cord,  in  the  saliva  and 
parotid  gland,  and  in  the  aqueous  humor  of  four  dogs  dying  of  the  disease. 
Fluid  media,  especially  bouillon  and  glucose  acidulated  with  tartaric  acid,, 
were  found  best  adapted  for  culture  experiments. 

TTie  microbe  of  hydrophobia  exists,  but  so  far  it  has  not  been  discovered. 


CAUSES.  463 

That  hydrophobia  is  a  microbic  disease  can  no  longer  be  doubted.  At  the 
present  time  we  can  safely  assert,  without  fear  of  contradiction,  that  the 
essential  cause  of  this  disease  is  a  specific  virus,  which  can  only  be  repro- 
duced within  the  living  organism.  As  a  small  quantity  of  this  virus  intro- 
duced in  the  tissues  can  result  in  the  most  serious  consequences,  there  exists 
no  doubt  that  it  possesses  the  properties  pertaining  to  living  organisms,  more 
especially  the  capacity  of  reproduction  after  its  entrance  into  the  body. 
That  the  disease  is  not  caused  by  preformed  toxins,  communicated  from  the 
saliva  of  rabid  animals,  is  shown  by  the  variable  and,  on  the  whole,  long 
stage  of  incubation  which  precedes  all  true  infective  processes.  That  hydro- 
phobia is  not  caused  by  a  soluble  virus  has  also  been  shown  by  the  experi- 
ments of  Peuch.  He  triturated  the  brain  of  an  hydrophobic  animal  and 
filtered  it  under  a  pressure  equivalent  to  3  atmospheres.  The  clear  filtrate, 
when  injected  into  animals  susceptible  to  this  disease,  proved  harmless; 
while  the  residue  on  the  filter,  when  used  in  a  similar  manner,  invariably 
produced  positive  results.  Another  convincing  proof  of  its  microbic  origin 
is  the  well-established  fact  that  the  disease  can  be  artificially  produced  by 
implanting  fragments  of  brain-  or  cord-  tissue,  taken  from  animals  dead  of 
rabies,  into  healthy  animals.  Furthermore,  the  blood  and  secretions  of  a 
rabid  animal,  its  flesh  and  viscera,  even  the  cooked  flesh  of  a  rabid  ox,  when 
eaten,  would  seem  to  be  capable  of  conveying  the  disease.  A  pupil  at  the 
veterinary  school  of  Copenhagen  inoculated  himself  with  the  virus  by  cut- 
ting his  finger  slightly,  while  examining  the  body  of  a  dog  that  had  died  of 
rabies  on  the  evening  before;  the  studient  died  of  hydrophobia  in  six  weeks. 
The  clinical  symptoms,  as  well  as  the  pathological  conditions  found  in  the 
brain  and  spinal  cord  of  hydrophobic  patients,  bear  such  a  strong  resem- 
blance to  tetanus  that  it  appears  probable  that  the  microbe  possesses  anal- 
ogous pathogenic  properties,  and  that  the  actual  development  of  the  disease 
follows  the  action  of  its  toxins  upon  the  central  nervous  system.  The  latent 
stage  of  the  disease,  or  the  long  duration  of  the  period  of  incubation,  depends 
either  upon  the  slow  growth  of  the  microbes  or  that  these  reach  the  place 
slowly  from  where  they  exert  their  specific  pathogenic  properties. 

CAUSES. 

The  microbe  of  hydrophobia  does  not  penetrate  the  intact  skin  or 
healthy  mucous  membrane;  hence  its  entrance  into  the  tissues  takes  place 
through  an  infection-atrium:  usually  a  punctured  wound  made  by  the  bite 
of  a  rabid  animal.  As  the  microbe  preexists  in  the  saliva  of  the  rabid  animal, 
inoculation  takes  place  at  the  time  the  wound  is  inflicted.  Infection,  how- 
ever, can  take  place  by  the  deposition  of  the  infected  saliva  upon  a  surface 
from  which  absorption  can  take  place.  This  can  occur  from  the  licking  of 
a  wound  or  abraded  surface  by  an  infected  dog,  as  happened  in  one  of  my 


464  PKINCIPLES    OF    SUEGERY. 

cases.  In  another  case  a  lady  of  rank  and  fashion  had  a  pimple  on  her  face, 
from  which  she  had  scratched  off  the  head.  Hydrophobia  was  thus  con- 
tracted, and  she  perished  by  this  terrible  disease. 

SYMPTOMS   AND    DIAGNOSIS. 

Great  diversity  of  opinion  exists  as  to  the  length  of  the  period  of  in- 
cubation in  man.  In  the  2  cases  of  hydrophobia  that  have  come  under  my 
own  observation  the  time  of  infection  and  the  onset  of  the  disease  could  be 
accurately  fixed,  and  in  both  of  them  the  stage  of  incubation  lasted  forty-two 
days.  In  106  cases  of  hydrophobia  in  human  beings  of  all  ages,  collected 
by  Bouley,  23  occurred  within  two  months  after  infection,  and  the  re- 
mainder came  in  at  varying  periods,  the  longest  time  noted  being  eight 
months.  The  cases  reported  where  it  was  supposed  the  disease  developed 
some  years  after  the  persons  were  bitten  by  a  dog  lack  accuracy  of  obsrva- 
tion,  and  either  the  diagnosis  was  not  correct  or  infection  occurred  more 
recently,  as  we  have  the  authority  of  Fleming  that  the  disease  never  occurs 
later  than  eight  months  after  inoculation.  Age  appears  to  have  some  in- 
fluence in  modifying  the  duration  of  the  stage  of  incubation.  In  the  cases 
where  the  length  of  this  stage  could  be  accurately  ascertained,  in  patients 
under  20  years  of  age  the  mean  period  of  incubation  was  six  weeks;  from 
20  up  to  72  it  was  two  months  and  a  half.  Before  the  actual  d-evelopment 
of  the  disease  in  man  there  is  usually  a  period  of  a  few  days  during  which 
ill-defined  premonitory  symptoms  can  be  detected.  The  wound  through 
which  the  virus  entered  is  the  seat  of  a  sensation  of  uneasiness  and  itching, 
and  sometimes  of  actual  pain,  which  radiates  along  the  course  of  the  nerves 
of  a  limb.  The  cicatrix  often  presents  a  congested  appearance,  and  is  tender 
on  pressure.  The  patient  is  melancholic  and  irritable,  and  sleep  is  disturbed. 
The  first  characteristic  symptom  of  hydrophobia  in  man  is  a  sense  of  tight- 
ness and  choking  about  the  pharynx,  attended  by  a  hesitation  in  swallowing, 
especially  of  liquids.  In  one  of  my  cases  this  early  disturbance  of  the  func- 
tion of  the  muscles  of  deglutition  made  it  possible  for  me  to  recognize  the 
disease  a  few  hours  after  the  attack  commenced.  The  patient  was  a  sailor, 
about  30  years  of  age,  who  sent  for  me  to  treat  him  for  a  supposed  cold. 
The  only  thing  he  complained  of  was  a  sense  of  constriction  in  the  throat 
and  difficulty  in  swallowing.  In  examining  the  cavity  of  the  mouth  and 
pharynx  for  evidences  which  would  explain  the  existing  symptoms  I  found  a 
profuse  salivary  secretion;  the  mucous  membrane  of  the  pharynx  was  con- 
gested, but  no  signs  of  deep-seated  inflammation  could  be  found  in  the  re- 
gion of  the  tonsils.  My  suspicions  were  awakened  at  once.  I  ascertained 
that  six  weeks  before  a  small  pet  dog  owned  by  the  family  had  died  after  a 
few  days  of  illness,  and  that  one  day  during  this  time,  when  the  patient  was 
lying  on  his  back  on  the  floor,  the  dog  had  licked  a  small  sore  on  the  ante- 


SYMPTOMS   AND    DIAGNOSIS.  465 

rior  surface  of  the  lobe  of  the  left  ear.  Eequesting  the  patient  to  drink  water 
from  a  glass  which  I  handed  him,  I  noticed  a  hesitation  on  his  part  to  com- 
ply with  my  wish;  but  finally  he  grasped  the  glass  with  both  hands,  which 
trembled  considerably,  and,  after  waiting  for  the  proper  moment  to  come, 
applied  it  rapidly  to  his  lips  and  made  a  desperate,  but  futile,  effort  to  swal- 
low; the  attempt  was  repeated  several  times,  but  only  a  very  small  amount 
was  swallowed.  The  next  group  of  muscles  to  become -affected  with  con- 
vulsive spasms  are  the  muscles  of  respiration  about  the  larynx.  The  symp- 
*toms  of  a  well-developed  case  of  hydrophobia  are  so  well  depicted  by  Flem- 
ing that  I  will  give  his  own  description:  "The  difficulty  in  swallowing 
rapidly  increases,  and  it  is  not  long  before  the  act  becomes  impossible,  un- 
less it  is  attempted  with  determination,  though  even  then  it  excites  the  most 
painful  spasms  in  the  back  of  the  throat,  with  other  indescribable  sensations, 
all  of  which  appall  the  patient  and  cause  him  to  dread  thoovery  thought  of 
liquids.  Singular  nervous  paroxysms  or  tremblings  become  manifest,  and 
sensations  of  stricture  and  oppression  are  felt  about  the  throat  and  chest. 
The  breathing  is  painful  and  embarrassed,  and  interrupted  with  frequent 
sighs  or  a  peculiar  kind  of  sobbing  movement,  or  catching  of  the  breath; 
there  is  a  sensation  of  impending  suffocation  and  of  necessity  for  fresh  air. 
Indeed,  the  most  marked  symptoms  consist  in  a  horribly- violent  convulsion 
or  spasm  of  the  muscles  of  the  larynx  and  pharynx,  or  gullet,  by  which  swal- 
lowing is  prevented,  and  at  the  same  time  the  entrance  of  air  into  the  wind- 
pipe is  greatly  retarded.  Shuddering  tremors,  sometimes  amounting  to  gen- 
eral convulsions,  run  through  the  whole  frame,  and  a  fearful  expression  of 
anxiety,  terror,  and  despair  is  depicted  on  the  countenance." 

Frothing  at  the  mouth  is  rarely  observed,  but  th-e  viscid,  tenacious  mu- 
cus in  the  fauces  and  the  profuse  salivary  secretion  are  frequently  forcibly 
ejected  by  hawking  and  spitting.  Shortly  before  death  the  patient's  mouth 
is  often  full  of  this  mucus  or  froth,  which  in  some  cases  is  tinged  with  blood. 
The  pulse  at  first  is  not  much  changed  in  force  and  frequency,  but  as  the 
disease  advances  it  becomes  feeble  and  rapid,  and  often  intermittent.  The 
temperature  is  always  increased.  In  both  of  my  cases  the  thermometer  reg- 
istered from  101°  to  103°  F.  at  different  times  in  the  axilla.  A  post-mortem 
temperature  of  106.2°  F.,  taken  in  the  rectum  immediately  after  death,  has 
been  recorded. 

Occasionally  the  patient  has  hallucinations  of  sight  and  hearing,  but 
usually  the  mental  faculties  are  not  much  impaired.  One  patient,  alluded 
to  by  Trousseau,  heard  the  ringing  of  bells,  and  some  mice  run  about  on  his 
bed.  To  the  by-stander  the  most  distressing  phenomenon  presented  by  hy- 
drophobic patients  is  the  fear  of  impending  death,  which  is  usually  mani- 
fested soon  after  the  attack,  and  remains  throughout  the  whole  course  of  the 
disease.    ISTo  kinds  of  assurances  or  consolations  are  able  to  dispel  it.    Death 


466  PRINCIPLES    OP    SUEGERY, 

occurs  from  complete  exhaustion,  in  most  cases  attended  by  well-marked 
evidences  of  asphyxia  from  spasm  of  the  glottis;  sometimes  a  convulsion 
is  the  final  symptom,  as  in  tetanus. 

The  differential  diagnosis  between  hydrophobia  and  tetanus  is  not  al- 
ways easy.  In  both  diseases  the  stage  of  incubation  is  variable,  and  both  are 
characterized  by  excessive  excitability  of  the  cerebro-spinal  centre,  as  is  evi- 
dent from  the  muscular  spasms  and  great  hypersesthesia  of  the  entire  surface 
of  the  body  during  the  stage  of  irritation.  In  hydrophobia  infection  always 
takes  place  from  the  bite  of  a  rabid  animal,  and  the  difficulty  in  swallowing 
is  caused  by  spasm  of  the  pharyngeal  muscles,  and  not  by  tonic  contraction 
of  the  muscles  of  mastication,  notably  the  masseters,  as  is  the  case  in  tetanus. 
In  tetanus  respiration  is  impaired  by  rigidity  of  the  respiratory  muscles  of 
the  chest;  in  hydrophobia  by  spasmodic  contractions  of  the  respiratory  mus- 
cles of  the  larynx.  Acute  softening  of  the  brain,  and  meningitis  affecting 
the  base  of  the  brain  and  upper  portion  of  the  spinal  cord,  may  give  rise  to 
symptoms  that  bear  a  faint  resemblance  to  the  clinical  picture  of  hydro- 
phobia, but  a  careful  study  of  the  symptoms,  individually  and  collectively, 
will  disclose  the  real  nature  of  the  case  under  consideration.  A  purely'neu- 
rotic  affection  has  been  described  as  lyssa  nervosa  falsa,  which,  it  has  been 
said,  resembles  genuine  hydrophobia  closely.  Such  cases  are  undoubtedly 
one  of  the  manifold  manifestations  of  hysteria;  and,  if  so,  it  can  be  differ- 
entiated from  true  hydrophobia  by  the  absence  of  fever  and  by  the  fact  that 
the  muscular  spasms  are  not  limited  to  the  muscles  of  deglutition  and  the 
muscles  of  the  larynx.  Trousseau  speaks  of  lyssa  nervosa  falsa  as  a  mental 
hydrophobia.  Fayrer  describes  a  case  of  this  kind  in  a  young  Scotchman  in 
India,  and  Bollinger  quotes  a  case  of  a  boy  who  was  twice  frightened  into 
simulated  hydrophobia. 

In  making  a  positive  final  diagnosis  of  hydrophobia  it  is  necessary  to 
establish,  in  the  first  place,  the  fact  that  infection  occurred  from  a  rabid 
animal  within  eight  months  from  the  development  of  the  disease;  and,  in 
the  second  place,  it  is  necessary  to  prove  the  existence  of  spasms  of  the  mus- 
cles of  deglutition  in  attempts  to  swallow  liquids;  and  if  at  the  same  time 
spasms  of  the  muscles  of  the  larynx  interfere  with  the  function  of  respira- 
tion, all  doubt  as  to  the  nature  of  the  difficulty  has  been  removed. 

PROGNOSIS. 

If  any  doubt  existed  as  to  the  nature  of  the  case  during  life,  an  early 
fatal  termination  will  corroborate  the  suspicions  that  may  have  been  enter- 
tained. Decroix  reports  9  cases  of  spontaneous  recovery  in  dogs.  In  man 
this  terrible  disease  is  invariahly  fatal;  there  is  no  authentic  instance  on  record 
of  recovery  from  genuine  hydrophobia.  Death  results  unexpectedly,  suddenly, 
or  from  apoplexy,  asphyxia,  or  exhaustion,  in  from  twelve  hours  to  six  days 


PATHOLOGY   AND    MOEBID    ANATOMY. 


467 


from  the  appearance  of  the  first  symptoms.  The  mean  duration  of  the  dis- 
ease is  about  four  days.  One  of  my  patients  died  on  the  fourth  and  the  other 
on  the  fifth  day  after  the  attack.  In  90  cases  collected  by  Bouley,  death  oc- 
curred in  74  during  the  first  four  days,  the  largest  proportion  of  these  being 
on  the  second  and  third  days.  In  only  16  was  life  prolonged  beyond  the 
fourth  day. 

PATHOLOGY   AND    MOEBID   ANATOMY. 

Hydrophobia,  like  tetanus,  to  which  disease  it  is  so  closely  allied  in 
many  respects,  is  characterized  by  the  absence  of  gross  pathological  changes 


Fig.  160. — A  Blood-vessel  from  Medulla  Oblongata  in  a  Case  of  Hydrophobia, 
numbers  of  round  cells  are  seen  in  its  sheath.     X  350.     (Coates.) 


Large 


in  the  nervous  centres  and  at  the  primary  seat  of  infection.  The  scar  which 
marks  the  wound  or  lesions  through  which  infection  occurred  may  be  red 
and  slightly  swollen,  but  these  changes  are  not  present  in  all  cases.  Hydro- 
phobia is  a  disease  in  which  there  is  every  indication  of  irritation  of  certain 
nerve-centres  and  of  a  greatly-increased  reflex  irritability.  The  centres  irri- 
tated here  are  less  those  of  the  cerebral  hemispheres  than  of  the  spinal  cord 
and  medulla  oblongata.  The  symptoms  point  mainly  to  the  medulla  ob- 
longata, and  after  death  well-defined  vascular  lesions  can  be  detected  in  this 
structure  by  means  of  the  microscope. 

Similar  lesions,  but  less  marked,  can  be  found  in  the  spinal  cord,  and 


468 


PKINCIPLES    OF    SUEGEEY. 


still  to  a  lesser  degree  in  the  other  parts  of  the  nervous  system.  The  most 
prominent  condition  is  an  accumulation  of  leucocytes  around  the  vessels  in 
the  substance  of  the  cord  and  medulla  oblongata  (Fig.  160).  Where  the  local 
lesion  is  most  advanced  the  vessels  are  surrounded  by  several  layers  of  leu- 
cocytes, which  would  indicate  that  the  microbe  of  hydrophobia  or  its  toxins 
produce  an  alteration  of  the  capillary  wall  of  sufficient  intensity  to  entitle 
the  process  to  be  called  inflammation.  An  increase  of  leucocytes  is  evident 
everywhere,  so  much  so  that  the  collections  which  can  be  found,  in  different 
parts  have  been  called  miliary  abscesses.  As  the  leucocytes  show  no  evi- 
dences of  even  approaching  transformation  into  pus-corpuscles,  these  aggre- 
gations of  leucocytes  do  not  deserve  the  name  of  abscesses.  Klebs  is  of  the 
opinion  that  the  microbe  of  hydrophobia  does  not  enter  the  circulation  di- 
rectly, but  invades  in  preference  the  lymphatic  vessels,  as  he  found  general 


Fig.  161. — From  the  Salivary  Gland  in  a  Case  of  Hydrophobia.  In  the  middle  is  the 
portion  of  a  duct;  abundant  round  cells  abound  it  as  well  as  the  glandular  structures 
shown  in  outline.     X  350.     (Coates.) 


lymphatic  engorgement  in  a  recent  case.  The  same  author  also  discovered, 
particularly  in  the  submaxillary  gland,  deposits  of  finely  granular,  strongly 
refractive  corpuscles  of  a  faint,  brownish  color,  closely  packed  together  in 
clusters  and  rows,  which  he  regards  as  possibly  the  vehicles  for  the  trans- 
portation of  the  specific  virus.  Well-marked  evidences  of  leucocytes  have 
been  found  by  many  in  the  salivary  glands. 

There  is  hypersemia  and  oedema  of  the  substance  of  the  brain,  medulla 
oblongata,  and  cord,  and  of  their  membranes;  deep-red  injection  of  the 
mucous  membrane  of  the  pharynx  and  epiglottis,  and  sometimes  recent 
swelling  of  the  tonsils,  follicular  glands  of  the  tongue,  pharyngeal  follicles, 
and  of  the  lymphatic  glands  in  the  neighborhood  of  the  jaw.  The  stomach 
and  intestines  show  decided  injection,  and  often  hemorrhagic  extravasations. 
The  lungs  are  charged  with  blood,  with  frequent  points  of  capillary  hgemor- 


TEEATMENT.  469 

liiage,  and  sometimes  emphysema  as  a  result  of  tlie  dyspnoea.  In  the  kid- 
neys, also,  there  are  signs  of  irritation  in  the  form  of  dilatation  of  vessels  and 
hfemorrhage.  According  to  Bollinger,  the  anatomical  picture  bears  the 
strongest  resemblance  to  that  seen  in  cases  of  death  from  asphyxia  or  thirst. 
The  conditions  found,  post-mortem,  furnish  an  illustration  that  here  an  in- 
tense irritant  is  circulating  in  the  blood,  and  the  intensity  of  it  may  be 
judged  from  the  fact  that  all  these  very  marked  appearances,  although  nearly 
all  of  them  recognized  only  by  the  use  of  the  microscope,  occur  in  the  short 
space  of  three  or  four  days. 

Tschernischeif  has  made  a  careful  study  of  the  microscopical  morbid 
anatomy  of  hydrophobia  in  man  based  u.pon  a  fatal  case.  In  the  dorsal  and 
lumbar  regions  of  the  cord  he  found  intense  hypersemia  in  the  white  and 
gray  substances,  with  an  infiltration  of  the  perivascular  lymph-spaces  by 
lymphoid  cells.  Black  agglomerations  were  found  at  the  periphery  of  the 
white  substance  and  pigmentary  degeneration  of  the  cells  in  Clarke's  col- 
umns. Numerous  cells  of  the  anterior  horns  of  Clarke's  columns  appeared 
deformed  and  altered,  presenting  chromatolysis.  The  nuclei  were  displaced 
peripherally  and  deprived  of  their  envelopes,  and  sometimes  more  intensely 
stained  than  the  cell-body.  In  some  cells  the  processes  were  detached.  All 
these  changes  were  most  marked  in  the  cervical  portion  of  the  cord.  Small 
extravasations  of  blood  were  found  in  the  floor  of  the  fourth  ventricle.  The 
pathological  changes  were  less  pronounced  in  the  cortex  of  the  brain,  the 
basal  ganglia,  the  cerebellum,  and  isthmus. 

TEEATMENT. 

As  hydrophobia  is  an  absolutely-fatal  disease,  the  treatment  resolves 
itself  into  prophylactic  measures  to  prevent  the  disease,  and  means  of  pal- 
liation after  it  has  developed. 

Prophylactic  Treatment. — The  most  effective  prophylactic  measures 
consist  in  preventing  the  spread  of  the  disease,  among  animals,  by  the  kill- 
ing or  strict  isolation  of  animals  which  present  symptoms  of  rabies.  If 
animals  which  are  suspected  of  being  rabid  are  known  to  have  bitten  per- 
sons, they  should  not  be  killed  at  once,  but  should  be  kept  in  close  confine- 
ment unknown  to  the  injured  person,  until,  by  observation  or  the  course  of 
the  disease,  a  positive  diagnosis  can  be  made.  As  soon  as  a  positive  diagnosis 
of  rabies  can  be  made,  then  the  animal  should  be  killed  to  prevent  any 
further  possibility  of  infecting  other  animals  or  persons.  If  a  person  is 
bitten  by  an  animal  which  presents  suspicious  symptoms,  no  time  should  be 
lost  to  prevent  infection  by  removing  or  destroying  the  virus. 

(a)  Excision  of  Wound. — As  the  virus  of  hydrophobia  appears  to  be 
slowly  diffused  in  the  tissues,  thorough  local  treatment  of  the  wound  may 
prove  successful  in  preventing  infection,  even  if  .resorted  to  several  hours  or 


470  PRINCIPLES    OF    SUEGEEY. 

days  after  inoculation  has  occurred.  As  soon  as  possible  after  the  bite  has 
been  inflicted,  a  constrictor  should  be  applied  on  the  proximal  side  of  the 
wound  and  medical  aid  summoned  without  delay.  In  the  meantime  an  at- 
tempt should  be  made  to  remove  the  virus  from  the  wound  by  suction.  In 
recent  cases  the  simplest  and  safest  treatment  consists  in  excising  the  tissues 
in  the  immediate  vicinity  of  the  puncture,  and  after  thorough  disinfection 
in  closing  the  wound  with  sutures. 

(b)  Cauterization  of  Wound.^ — The  same  object  is  accomplished,  but 
with  a  lesser  degree  of  certainty,  by  cauterization.  The  most  efficient  caustic 
is  the  actual  cautery.  With  the  knife-point  of  a  Paquelin  cautery  the  wound 
is  deeply  cauterized,  and  the  resulting  eschar  is  protected  against  infection 
with  pus-microbes  by  an  antiseptic  dressing.  Of  the  chemical  caustics  the 
most  valuable  are  caustic  potassa,  nitric  acid,  sulphuric  acid,  and  nitrate  of 
silver,  their  efficiency  being  estimated  in  the  order  named.  The  authority 
for  excision  and  thorough  cauterization,  as  prophylactic  measures,  is  to  be 
found  in  the  fact  that,  of  134  collected  cases,  in  which  bites  of  mad  dogs 
were  cauterized,  68  escaped  and  42  tlied:  a  degree  of  immunity  far  above  the 
average,  which  is  33  per  cent.  (Bouley). 

(c)  Prophylactic  Inoculations. — Pasteur  has  shown,  by  a  long  series  of 
inoculations,  made  first  in  monkeys,  rabbits,  and  guihea-pigs,  and  later  ex- 
clusively in  rabbits,  that  if  the  virus  of  hydrophobia  is  introduced  into  the 
brain  of  these  animals  the  disease  is  invariably  produced  after  a  fixed  period 
of  incubation.  As  the  period  of  incubation  in  successive  inoculations  in  the 
same  animal  is  shortened,  we  must  take  it  for  granted  that  the  virulence  of 
the  material  is  increased.  In  the  rabbit  the  first  inoculation  under  the  dura 
mater  is  followed  by  a  period  of  incubation  of  fourteen  days'  duration, 
which,  in  successive  inoculations  in  the  same  animal,  is  reduced  to  seven 
days.  Spinal  inoculations  in  dogs  produce  in  these  animals  fatal  rabies  in 
the  same  length  of  time.  Pasteur  made  an  additional  important  discovery, 
as  he  found  that  the  spinal  cord  of  the  inoculated  rabbits,  increased  in 
virulence  by  successive  inoculations,  is  again  diminished  in  its  virulence 
by  preserving  it  in  dry  air,  guarding  at  the  same  time  against  contami- 
nation with  other  microorganisms.  This  discovery  led  to  a  method  by 
which  the  virulent  action  of  such  preparations  can  be  accurately  graded, 
inasmuch  as  the  action  of  the  spinal  cord,  in  the  drying-room,  in  7  to  8  days 
is  reduced  from  its  highest  degree  of  virulence  to  nil.  By  using  the  spinal 
cord  of  rabbits  treated  in  this  manner  in  different  strengths,  at  first  weak 
and  then  gradually  stronger  preparations,  it  was  found  possible  to  render 
animals  immune  to  the  action  of  inoculation  material  of  the  highest  potency. 
By  this  method  Pasteur  succeeded  in  creating  absolute  immunity  against  the 
strongest  hydrophobic  virus  in  50  dogs.  The  success  of  these  prophylactic 
inoculations  in  animals  enabled  Pasteur  to  resort  to  the  same  method .  of 


TREATMENT. 


471 


treatment  in  persons  bitten  by  rabid  animals,  as  the  long  stage  of  incubation 
made  it  possible  to  carry  out  this  treatment  before  the  actual  development 
of  the  disease  was  expected.  The  first  human  being  subjected  to  this  treat- 
ment was  on  July  5,  1885,  and  from  that  time  until  the  close  of  the  year 
1889  2682  persons  bitten  by  rabid  animals,  or  animals  that  were  suspected 
of  being  mad,  with  the  result  that  of  this  large  number  only  31  died,  equiv- 
alent to  1.15  per  cent.,  while  the  general  mortality  in  persons  under  similar 
circumstances  without  such  prophylactic  inoculations  has  been  at  least  16 
per  cent.  The  danger  is  always  greatest  when  the  bite  is  inflicted  by  rabid 
wolves.  Pasteur  collected  100  cases  of  persons  bitten  by  rabid  wolves,  and 
of  this  number  not  less  than  82  died.  Pasteur  had  an  opportunity  to  submit 
to  his  treatment  38  persons  bitten  by  rabid  wolves,  and  of  this  number  only 
3  died:   a  mortality  of  7.89  per  cent. 

The  following  tables  represent  Pasteur's  work  for  four  years: — 


Table  A. 

Ta 

BLE 

B. 

Table 

C. 

Total. 

t^'^ 

!>i^ 

>-.^ 

>>^ 

Yeaks. 

4^  -^ 

'£'6 

'6 

'6 

4^  4^ 

•^  a 

2 -3 

o 

»2 

P 

o  fe 

«2 

fi 

S2 

a 

S  s- 

Sg 

s 

°  is 

^H 

§a 

P-'.H 

^s 

I^H 

Sa 

f^H 

'^B 

1886  .... 

231 

3 

1.30 

1926 

19 

0.99 

514 

3 

0.58 

2671 

25 

0.94 

1S87  .... 

357 

2 

0.56 

1156 

10 

0.86 

257 

1 

0..39 

1770 

13 

0.73 

IS.'SS  .... 

402 

« 

1.49 

972 

2 

0.21 

248 

1 

0.40 

1622 

9 

0.55 

1889  .... 

316 

2 

0.58 

1187 

2 

0.17 

297 

2 

0.67 

1830 

6 

0.33 

Total  .   .   . 

1336 

18 

0.97 

5241 

33 

0.63 

1.316 

7 

0.52 

7893 

1 

53 

0.67 

The  bites  have  been  divided  into  three  categories, — (1)  those  of  the  head 
and  face;  (2)  those  of  the  hands;  (3)  those  of  the  limbs  and  trunk, — with 
the  following  result: — 


Tables  A  and  B. 

Table 

C. 

Total. 

pHfH 

■d 

Q 

s 

■d 

s 

1.  Head  and  face 

2.  Hands      

593 
376S 
2216 

14 

26 

6 

2.36 
0.69 
0.27 

79 
619 
618 

1 

3 
3 

127 
0.48 
0.48 

672 
4387 
2834 

15 

29 

9 

2.23 
0.66 

3.  Limbs  and  trunk 

0.32 

1'otal  .   .              

6577 

40 

0.70 

1316 

7 

0.53 

7893 

53 

0.67 

Table  A  comprises  those  persons  bitten  by  animals  determined  to  be 
rabid  by  experiments  in  rabbits,  made  in  the  laboratory,  or  by  the  death  of 
other  animals  or  persons  bitten  by  the  same  animal. 


472  PKINCIPLES    OF    SUEGEET. 

Table  B  comprises  those  persons  bitten  by  animals  demonstrated  to  be 
rabid  by  the  examination  of  a  veterinary  snrgeon,  or  by  the  clinical  signs 
shown  during  life. 

Table  C  comprises  those  persons  bitten  by  animals  suspected  to  be 
rabid. 

Gribier  has  treated  610  persons  having  been  bitten  by  dogs  or  cats  since 
the  New  York  Pasteur  Institute  was  opened  until  October  15^,  1890.  For 
480  of  these  persons  it  was  demonstrated  that  the  animals  which  attacked 
them  were  not  mad.  Consequently  the  patients  were  sent  back  after  having 
had  their  wounds 'attended,  during  the  proper  length  of  time,  when  it  was 
necessary.  In  130  cases  the  antihydrophobic  treatment  was  applied,  hydro- 
phobia having  been  demonstrated  by  veterinary  examination  of  the  animals 
which  inflicted  the  bites,  or  by  the  inoculations  in  the  laborator}'-,  and  in 
many  cases  by  the  death  of  some  other  persons  bitten  by  the  same  animal. 
All  these  persons  were  fully  protected  by  the  prophylactic  inoculations. 

Proto'popoif  {CentralUatt  filr  Cliirurgie-,  October  18,  1890)  has  made 
some  experiments  which  tend  to  prove  that  Pasteur^s  prophylactic  inocula- 
tions accomplish  their  object  by  the  presence  of  a  fixed  virus,  and  not  from 
the  action  of  the  microbe  of  hydrophobia.  He  took  the  spinal  cords  of 
animals  which  had  died  of  rabies  and  removed  from  them  the  fixed  virus  by 
sterilization.  He  found  that  placing  such  cords  in  glycerin  bouillon  at  a 
temperature  of  from  65°  to  68°  F.  for  from  fifteen  to  twenty  days  accom- 
plished this  purpose,  and  that  an  emulsion  prepared  with  spinal  cords  treated 
in  this  way  can  be  used  as  a  sterilized  culture  of  the  virus.  A  series  of  ex- 
periments and  control  experiments  by  the  same  author  showed  that  immu- 
nity against  experimental  rabies  could  be  secured  by  inoculating  animals 
with  the  non-poisonous  emulsion  just  described.  Out  of  19  dogs  protected 
by  inoculations  with  the  sterilized  virus,  14  were  protected  against  the  effects 
of  Pasteur's  virus,  while  every  one  of  the  14  animals  used  for  control  experi- 
ments died. 

Kraiouchki'ne  states  that,  in  the  year  1895,  269  persons  were  treated  in 
St.  Petersburg  for  hydrophobia  by  Pasteur's  method.  In  two  cases  the  dis- 
ease developed  before  the  treatment  was  completed,  another  patient  died- 
after  the  treatment,  giving  a  mortality  of  0.4  per  cent.  Lagorio,  of  the 
Chicago  Pasteur  Institute,  gives  the  result  of  his  work  since  1890,  to  date, 
May  1,  1900:— 

To  date,  a  grand  total  of  950  patients  received  the  antihydrophobic 
treatment. 

Eight  hundred  and  fifty-five  persons  were  bitten  by  dogs,  31  by  cats, 
35  by  horses,  11  by  skunks,  5  by  wolves,  4  by  cows,  2  by  calves,  1  by  a  rat, 
1  by  a  mule,  1  by  a  pig,  and  4  by  hydrophobic  human  beings.  Four  hun- 
dred and  sixty-two  persons  received  severe  and  multiple  lacerated  bites  on 


TEEATMENT. 


473 


the  hands  and  wrists,  131  on  the  head  and  face,  134  on  the  arms,  204  on  the 
legs  and  thighs,  and  29  on  the  trunk. 

Following  the  role  of  Pastenr,  the  patients  treated  have  heen  classified 
as  follows:  First:  Persons  bitten  by  animals  recognized  and  ascertained  to 
be  rabid  by  the  test  experiment  made  in  the  laboratory  or  by  the  death  of 
other  persons  or  animals  bitten  by  the  same  animal.  Of  this  class,  368  were 
treated.  Second:  Persons  bitten  by  animals  recognized  to  be  rabid  by  the 
symptoms  of  the  disease  shown  during  life.  Of  this  class,  420  were  treated. 
Third:  Persons  bitten  by  animals  strongly  suspected  to  be  rabid.  Of  this 
class,  162  were  treated. 

Only  5  deaths  have  been  reported,  thus  giving  a  mortality  of  0.52  per 
cent. :  a  result  which  we  consider  marvelous  when  accurate  statistics  tell  us 
that,  before  the  discovery  of  the  Pasteur  treatment,  the  mortality  was  as  high 
as  88  per  cent,  for  the  bites  of  the  face,  67  per  cent,  for  bites  of  the  hands, 
and  20  to  30  per  cent,  for  the  bites  of  the  limbs  and  trunk. 

Three  patients  were  overtaken  with  hydrophobia  at  the  Institute  while 
under  treatment.  This  was  due  to  the  lateness  of  their  coming,  many  days 
having  passed  since  they  were  bitten.  Hence,  we  cannot  urge  too  strongly 
the  necessity  for  applying  for  treatment  at  once  after  being  bitten.  Tli& 
sooner  the  letter.  Every  day  that  passes  shortens  the  period  of  incubation 
and  also  the  chances  of  successful  results. 

All  patients  tolerated  the  treatment  perfectly  well.  It  being  absolutely 
harmless,  it  can  be  taken  with  confidence  and  without  fear  of  injury  to  the 
health.  The  treatment  consists  in  hypodermic  injections  of  a  specially-pre- 
pared virus  of  different  gradation  of  strengths  for  a  period  of  fifteen  days, 
eighteen  days,  or  twenty-one  days,  according  to  the  severity  of  the  case.  The 
method  used  is  identical  with  that  used  in  Paris. 

These  results  must  convince  the  most  skeptical  of  the  practical  utility 
of  Pasteur's  prophylactic  treatment  against  hydrophobia,  and,  although  the 
method  will  not  be  perfect  until  the  microbe  of  this  disease  is  discovered  and 
mitigated  (pure  cultures  are  employed),  this  crude  method  must  be  viewed 
as  a  great  boon  to  a  class  of  patients  otherwise  exposed  to  the  risks  of  con- 
tracting the  most  terrible  and  hopeless  of  all  diseases.  Pasteur  institutes 
have  sprung  up  in  different  parts  of  the  civilized  world,  and  the  acciimulated 
experience  of  all  those  engaged  in  this  kind  of  work  bears  strong  testimony 
in  favor  of  the  prophylactic  inoculations  against  hydrophobia  as  taught  and 
practiced  by  Pasteur.  At  the  bacteriological  laboratory  in  Cuba  306  persons 
have  been  treated  by  the  "double  intensive"  plan.  Of  these,  only  2  died  after 
going  through  the  full  course:  a  mortality  of  1.63  per  cent.  All  these  cases 
were  bitten  by  dogs  proved  experimentally  and  clinically  to  be  rabid,  or,  at 
any  rate,  suspected.  That  the  inoculations  were  conducted  with  due  con- 
servatism is  indicated  by  the  fact  that  only  306  persons  were  treated  out  of 


474  PEINCIPLES    OF    SUEGERY. 

700  applicants.  Some  of  the  failures  Pasteur  attributes  to  the  long  intervals 
between  the  prophylactic  inoculations,  and  in  grave  cases  he  now  advises  that 
successive  inoculations  should  be  made  with  cord-substance  twelve,  ten,  and 
eight  days  old,  during  the  first  twenty-four  hours;  on  the  second  day  with 
material  six,  four,  and  two  days  old;  on  the  eighth  day  with  material  one  day 
old,  to  be  followed  by  two  similar  series  of  inoculations.  By  following  this 
energetic  plan  of  prophylactic  treatment  he  has  been  able  to  secure  protection 
even  in  the  most  urgent  cases;  that  is,  in  cases  where  the  stage  of  incubation 
had  nearly  terminated. 

Palliative  Treatment.- — The  nature  of  the  disease  should,  under  no  cir- 
cumstances, be  disclosed  to  the  patient,  as  the  people,  high  and  low,  educated 
and  ignorant,  are  only  too  familiar  with  the  terrible  suffering  caused  by  this 
affection,  and  its  absolute  certainty  of  a  fatal  termination  in  a  few  days.  In 
one  of  my  cases  the  patient  had  been  made  acquainted  with  the  character  of 
the  ailment,  and  begged  'piteously  that  his  life  might  be  terminated  by  the 
administration  of  chloroform,  knowing  well  that  the  intense  suffering  would 
continue  to  the  last  moment.  As  light,  draughts  of  air,  and  noise  of  every 
kind  increase  the  suffering  by  exaggerating  convulsive  spasms,  these  aggra- 
vating causes  should  be  eliminated  from  the  patient's  room,  and  only  a  lim- 
ited number  of  persons  should  be  admitted  to  render  the  necessary  assistance 
and  carry  out  the  directions  of  the  attending  physicians.  As  the  saliva  of 
hydrophobic  patients  contains  the  specific  virus,  those  placed  in  charge  of 
the  patient  should  protect  themselves  against  inoculation  by  preventing  the 
contact  of  the  saliva  with  abraded  surfaces,  or,  still  better,  by  covering  any 
abrasions  which  may  exist  with  a  collodium  dressing.  Thirst  is  quenched 
by  administering  water  per  rectum.  Medicines  by  the  mouth  should  not  be 
given,  as  every  attempt  at  swallowing  brings  on  violent  spasms  of  the  mus- 
cles of  deglutition  and  the  respiratory  muscles  of  the  larynx.  Morphia  com- 
bined with  small  doses  of  atropia  should  be  given  subcutaneously  in  such 
doses  and  at  such  intervals  as  will  procure  rest.  The  subcutaneous  admin- 
istration of  quinine  and  woorara  has  been  advised,  but  both  of  these  remedies 
are  more  harmful  than  useful,  and  neither  of  them  adds  anything  to  the 
duration  of  life  or  alleviation  of  suffering.  The  only  remedy  which  can  be 
relied  upon  to  afford  prompt  relief  is  chloroform  by  inhalation.  Ether 
should  never  be  used,  as  the  hyper^mic  condition  of  the  brain  and  spinal 
cord  Avhich  is  present  in  every  case  of  hydrophobia  sufficiently  contraindi- 
cates  it.  The  inhalation  of  chloroform  must  be  conducted  by  an  assistant  or 
a  competent,  reliable  nurse,  and  should  never  be  carried  beyond  the  point 
where  relief  is  afforded,  and  it  should  be  repeated  as  often  as  the  paroxysms 
return. 


*  CHAPTER  XIX. 

Surgical  Tuberculosis. 

Tubercular  lesions  fiirnisli  a  most  excellent  illustration,  clinically  and 
■•under  the  microscope,  of  the  origin,  course,  termination,  and  tissue-changes 
of  what  is  known  as  chronic  inflammation.  A  histological  description  of  a 
tubercular  nodule  is  a  description  of  the  pathology  of  chronic  inflammation. 
Tuberculosis  in  all  its  forms  is  caused  by  a  specific,  microbe  the  action  of 
which  upon  the  tissues  produces  histological  and  vascular  changes  which  are 
characteristic  of  chronic  inflammation.  Of  all  the  microbic  diseases,  with 
the  exception  of  suppuration,  tuberculosis  is  of  the  greatest  interest  and  im- 
portance to  the  surgeon.  Of  the  greatest  interest  because  the  tubercular 
.  lesions  which  come  under  his  care  are  more  clearly  understood  from  a  bac- 
teriological stand-point  than  most  of  the  other  surgical  diseases,  and  of  the 
greatest  importance  on  account  of  their  great  frequency.  That  large  class  of 
ill-defined  lesions  which  were  grouped  under  that  indefinite  and  vague  term 
scrofula,  in  the  text-books  of  but  a  few  years  ago,  have  been  shown  by  recent 
research  to  be  identical  with  the  recognized  forms  of  tuberculosis,  etiolog- 
ically,  clinically,  and  anatomically.  In  this  chapter  I  shall  aim  to  give  a 
hrief  description,  from  a  bacteriological  and  clinical  stand-point,  of  such 
localized  tubercular  lesions  which,  by  general  consent,  are  regarded  as  sur- 
gical affections  and  requiring  surgical  procedures  in  their  successful  treat- 
ment. 

HISTORY  OF  THE  MICROBIC  ORIGIN"  OF  TUBERCULOSIS. 

The  first  inoculation  experiments  with  tubercular  products  were  made 
by  Kortum  in  1789  and  Cruveilhier  in  1826.  In  1834  Erdt  succeeded  in 
producing  numerous  nodules,  in  the  lungs  of  horses  by  inoculating  them  with 
tubercular  pus,  and  Klencke,  in  1843,  produ.ced  tuberculosis  in  rabbits  by 
intravenous  injections  of  tubercular  matter.  The  results  obtained  from  the 
crude  inocidation  experiments  which  were  made  years  ago  by  Villemin 
pointed  strongly  toward  the  infectiousness  of  tuberculosis.  Villemin's  ex- 
periments consisted  in  the  subcutaneous  insertion,  behind  the  ear  of  rab- 
bits, of  fragments  of  tubercu^lar  tissue,  or  fluid  taken  from  the  cavity  of  a 
tubercular  lung,  recently  removed  from  patients  who  had  died  of  pulmonary 
phthisis.  The  first  animal  thus  infected  was  killed  three  and  a  half  months 
after  inoculation.  The  lungs  and  most  of  the  internal  organs  were  found 
diffusely  infiltrated  with  miliary  tubercle.  His  numerous  later  experiments 
yielded  similar  results  and  led  him  to  the  following  conclusions:  "Phthisis 
of  the  lungs  (like  tubercular  diseases  in  general)  is  a  specific  infection.    Its 

(475) 


476  PEINCIPLES    OF    SUEGEEY. 

etiology  depends  on  an  inoculable  agent.    It  can  be  readily  commnnicated 
from  man  to  animal  by  inoculation." 

Vogel  repeated  the  experiments  of  Villemin  on  horses  without  success. 
Biffi,  Verga,  and  Sangalli  experimented  on  mules,  cows,  sheep,  dogs,  cats, 
mice,  and  chickens,  with  negative  results.  The  experiments  of  Langhans  led 
him  to  the  conclusion  that  tubercle  could  not  be  communicated  in  the  man- 
ner described  by  Villemin.  He  claimed  that  the  inoculation  material  acted  - 
only  the  part  of  a  foreign  body,  the  inflammation  following  its  insertion  into 
the  tissues  differing  in  no  way  from  the  ordinary  forms  of  inflammation. 
Among  those  who  made  successful  inoculation  experiments,  and  adopted  the 
doctrines  advanced  by  Villemin,  may  be  mentioned  Hevard  and  Cornil, 
Hoffmann,  Cohn,  Behier,  Empis,  Mantegazza,  Bizzozero,  Lebert  and  Wyss, 
Klebs,  Koester,  Waldenburg,  Bijuen,  Simon,  Sanderson,  W.  Fox,  Papillon, 
Mcol,  and  Laveran.  Hevard  and  Cornil  were  able  to  propagate  tuberculosis 
by  inoculations  with  crude  tubercular  material.  They  inoculated  with  gen- 
uine tubercular  material,  but  failed  with  cheesy  products.  Marcet  inoculated 
11  guinea-pigs  with  the  sputa  of  phthisical  patients,  and  in  10  of  them  the 
experiment  proved  successful.  Cohnheim  injected  tubercular  material  into 
the  anterior  chamber  of  the  eye  in  rabbits,  and  succeeded  in  producing  the 
disease  artificially  in  this  manner.  Hueter  produced  tuberculosis  of  the  iris 
by  inserting  into  the  anterior  chamber  of  the  eye  in  rabbits  fragments  of 
tubercular  tissue.  Toussaint  showed  that  true  tubercle,  both  in  man  and 
animals,  reproduces  itself  indefinitely  with  absolutely  constant  and  identical 
properties,  and  that  it  is  quite  capable  of  being  transmitted  from  animal  to 
animal  without  losing  its  virulence. 

Krishaber  and  Dieulafoy  experimented  on  monkeys,  and  the  results 
obtained  led  to  the  conclusions:  1.  That  human  tubercle,  when  inoculated, 
kills  a  monkey  in  nine  out  of  ten  cases,  with  lesions  analogous  to  those  met 
in  man.  2.  The  effect  of  the  inoculation  varies  according  to  the  substance 
employed;  the  gray  granulation  is  most,  and  "the  pulmonary  parenchyma 
least,  infectious.  Schuller  and  Lentz  made  successful  inoculations  with 
blood  taken  from  tubercular  rabbits.  Lippl,  Schweninger,  Tappeiner,  and 
Weichselbaum  succeeded  in  producing  the  disease  in  animals  by  inhalation. 
Successful  feeding  experiments  were  made  by  Chaveau,  Aufreeht,  and  Bol- 
linger. 

Since  Villemin  announced  the  inoculability  of  tuberculosis  diligent 
search  was  made  to  discover  and  isolate  a  specific  microorganism  which 
should  be  characteristic  of  this  disease.  The  first  cultivation  experiments 
were  made  by  Klebs  in  1877.  He  found,  by  examining  fresh  specimens  of 
tubercle  of  human  beings,  that  they  invariably  contained  bacteria.  He  culti- 
vated them  in  egg-albumen  and  Bergmann's  culture  fluid,  and  found,  by 
experiment,  that  the  cultures  produced  the  same  effect  in  causing  disease 


HISTOKY    OF    THE    MICKOBIC    OEIGIN    OF   TUBEKCULOSIS.  477 

by  inoculation  as  tlie  tissues  from  which,  they  were  grown.  Injections  of 
the  culture  under  the  skin,  into  the  muscles,  lungs,  pleural  and  peritoneal 
cavities,  caused  death  of  the  animals  from  tuberculosis.  Cultures  made  in 
a  similar  manner  from  scrofulous  glands  and  lupous  tissue  produced  the 
same  effect  in  animals.  Max  Schliller  repeated  the  experiments  of  Klebs 
with  the  same  results.  He  described  the  specific  microbe  as  round  and  rod- 
shaped  bacteria,  the  rods  bulbous  at  both  ends,  composed  of  two,  seldom 
more,  spherical  bodies.  He  found  these  microbes  in  great  abundance  in  tu- 
bercular joints  and  tubercular  foci  in  bone.  He  produced  the  disease  arti- 
ficially in  animals  which  were  previously  inoculated  by  making  contusions 
of  joints.  Other  workers  in  the  same  field  advanced  theories,  found  and  de- 
scribed microbes  which  were  supposed  to  bear  a  direct  etiological  relation- 
ship to  tuberculosis,  but  nothing  definite  was  known  on  the  subject  until 
the  founder  of  modern  bacteriology,  Eobert  Koch,  in  1882,  announced  to  the 
profession  his  great  discovery.  He  had  found  and  demonstrated  the  true 
and  essential  cause  of  tuberculosis,  the  bacillus  of  tuberculosis,  and,  in  his 
first  publication,  brought  such  convincing  proof  of  the  correctness  of  his 
claim  that,  with  few  exceptions,  it  brought  conviction  even  to  the  minds  of 
the  most  skeptical.  He  had  not  only  found  the  bacillus,  but  showed  that  it 
was  present  in  all  tubercular  lesions.  He  had  isolated  and  cultivated  the 
bacillus  from  tubercular  tissue;  and,  finally,  he  had  furnished  the  crucial 
test:  had  produced  tuberculosis,  artificially,  in  animals  by  inoculation  with 
pure  cultures. 

A  number  of  pathologists  who  inoculated  animals  with  non-tubercular 
material  claimed  that  they  had  produced  pathological  conditions  analogous 
to  those  found  in  animals  which  had  been  infected  with  the  virus  of  tuber- 
culosis. Fragments  of  sponge  implanted  in  the  abdominal  cavity  produce  a 
condition  which  resembles  tubercular  infiammation,  and  it  has  been  asserted 
that  powdered  glass  has  a  similar  property.  Schottelius,  Wargunin,  Weich- 
selbaum,  and  Martin  have  employed  various  substances  by  way  of  experi- 
ment, such  as  powdered  cheese,  brain-substance,  lycopodium-seed,  Cayenne 
pepper,  and  pulverized  cantharides.  They  caused  these  to  be  inhaled  in  the 
form  of  a  fine  spraj^,  with  the  result  that  they  were  almost  invariably  able  to 
produce,  in  different  animals,  an  eruption  of  nodules  in  the  lung  and  some- 
times in  other  organs.  With  Limburger  cheese  Weichselbaum  produced  an 
eruption  in  the  lungs  and  kidneys  of  dogs,  after  fifteen  inhalations  during 
seventeen  days,  which,*  histologically,  could  not  be  distinguished  from  the 
products  of  genuine  tuberculosis.  Further  experimentation  soon  showed 
that  these  were  instances  of  pseudotuberculosis;  that,  while  the  gross  ap- 
pearances of  the  lesions  resembled  true  tuberculosis,  inoculations  with  this 
material  never  reproduced  the  disease,  while  inoculations  with  tubercular 
tissue  could  be  done  through  a  series  of  animals  without  impairing  the 


DESCRIPTION    OF    BACILLUS    TUBEECULOSIS.  479 


DESCEIPTION  OF  BACILLUS  TUBEECULOSIS. 

The  tubercle  bacillus,  with  the  exception  of  the  bacillus  of  septicsemia 
in  mice,  is  the  smallest  of  the  known  bacilli.  The  length  of  each  rod  varies 
from  one-fourth  to  three-fourths  of  the  diameter  of  a  red  blood-corpuscle. 
The  thickness  corresponds  to  that  of  the  bacillus  of  sepsis  in  mice.  The  rods 
are  either  straight  or,  what  is  more  common,  bent  or  curved  near  the  centre. 

In  cultures  and  in  the  tissues  they  occur  singly,  in  pairs,  or  in  bundles. 
In  a  state  of  fructification  the  bacilli  contain  from  two  to  six  spores.  In 
stained  rods  the  spores  appear  as  clear,  minute,  ovate  spaces,  as  they  are  not 
affected  by  the  coloring  material.  In  some  bacilli  the  spores  form  slight  pro- 
jections on  the  sides  of  the  rod.  Eeproduction  by  spore-formation  also  takes 
place  in  the  tissues  within  the  animal  body.  In  badly-stained  specimens,  and 
on  superficial  examination,  the  spores  impart  to  the  bacillus  the  appearance 
of  a  chain  coccus;  but,  examined  closely,  it  is  seen  that  the  protoplasm  of 
the  bacillus  is  continuous,  and  the  apparent  interruptions  are  due  to  the 
presence  of  the  spores.  The  bacilli  of  tuberculosis  are  non-motile,  and  con- 
sequently possess  no  power  of  locomotion,  and  cannot  penetrate  into  the 
tissues  without  assistance.  In  the  tissues  they  are  found  in  the  interior  of 
giant  cells  and  within  and  between  epithelioid  cells.  They  are  constantly 
found  in  places  where  the  tubercular  process  is  commencing  or  actively 
progressing.  In  the  beginning  they  are  isolated  and  in  the  interior  of  cells; 
later,  they  become  more  abundant  and  form  groups.  In  cheesy  deposits  they 
are  either  entirely  absent  or  few  in  number.  The  virulence  of  caseous  mate- 
rial is  due  mostly  to  the  presence  of  spores,  which  may  remain  in  a  latent 
condition  and  yet  retain  their  power  of  reproduction  under  more  favorable 
conditions  for  an  indefinite  period  of  time.  As  soon  as  giant  cells  appear, 
they  contain  bacilli  in  their  interior,  as  a  rule.  In  some  giant  cells  only  one 
bacillus  can  be  found,  and  then  it  occupies  a  part  of  the  cell  which  contains 
no  nuclei. 

In  giant  cells  with  numerous  bacilli  the  latter  arrange  themselves 
around  the  periphery  in  the  interior  of  the  cell,  while  the  centre  contains 
few  or  none. 

The  first  ingress  of  bacilli  into  the  diseased  tissues  probably  takes  place 
by  wandering  cells,  which  transport  the  non-motile  microbe.  In  many 
inoculation  experiments  such  bacilli-containing  cells  have  been  found  in 
the  blood  and  tissues. 

Staining. — The  peculiar  behavior  of  the  bacillus  of  tuberculosis  to  dif- 
ferent staining  material  enabled  Koch  not  only  to  discover  this  microbe,  but 
also  to  differentiate  it  from  all  other  microbes.  While  the  aniline  dyes  and 
other  nuclear  staining  material  showed  no  microorganisms  in  tubercular 
products,  the  bacillus  came  plainly  into  view  if  a  small  quantity  of  alkali 


480 


PEINCIPLES    OP    SURGERY. 


were  added  to  the  aniline  solution.  Later  experience  proved  that  the  same 
effect  is  produced  if,  instead  of  an  alkali,  aniline,  toluidin,  turpentine,  car- 
bolic acid,  or  ammonia  is  added.  All  of  these  substances  aid  the  penetration 
of  the  staining  fluid  into  the  bacillus.    Of  especial  advantage  is  the  discovery, 


Fig.  164. — Giant  Cell  with  One  Tubercle  Bacillus.    Section  from  lupus  of  skin. 
700:1.     (Flilgge.) 

also  made  by  Koch,  that  the  staining  fluid  is  fixed  more  permanently  by 
treating  with  nitric  or  muriatic  acid  the  sections  stained  with  alkaline  ani- 
line dyes:  a  procedure  which  removes  the  staining  from  the  cells,  nuclei,  and 
all  other  bacteria,  while  the  tubercle  bacillus  alone  remains  stained.     The 


Fig.  165.— Giant  Cell  (Miliary  Tuberculosis).    700:1.     (Flilgge.) 

preparation  is  further  completed  by  staining  once  with  one  of  the  ordinary 
aniline  dyes,  which  stains  the  cells  and  nuclei  and  other  bacteria,  so  that  the 
tubercle  bacillus,  for  instance,  appears  red,  the  nuclei  and  other  bacteria 
blue. 


.^^^ 


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1/  f 


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■■^&^-    \     \      / 


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// 


\ 


Fig.  166. — Glass-Slide  Preparation  from  the  Tissue-juice  of  a  Fresh  Inoculation- 
tubercle.  (Bhrlich's  staining.  Zeiss,  homog.  immers.,  V12I  0.4;  magnified  about  1500 
times.)     (Baumgarten.) 


Fig.  167. — Giant  Cell  with  Radiating  Arrangement  of  Bacilli.     From  encysted  bronchial 
glands  in  miliary  tuberculosis.     700  diam.     (Koch.) 


Fig.  168. — Tubercle  Bacilli.  Colony  on  solidified  blood-serum,  fourteen  days  old; 
stained  with  carbol-fuchsin,  decolorized  with  dilute  nitric  acid.  X  100.  (Frankel  and 
Pfeiffer.) 


DESCEIPTION    OF   BACILLUS    TUBERCULOSIS.  481 

Most  of  the  bacilli  (Fig.  163)  contain  spores,  the  majority  of  them 
slightly  curved  or  bent;  they  lie  free, — that  is,  outside  the  cells.  Where 
they  appear  to  be  within  the  cells,  a  close  examination  shows  them  to  be 
either  upon  or  underneath  the  cells. 

For  section-staining  Ehrlich's  method  is  the  best: — 

Saturated  alcoholic  solution  of  methyl-violet  or  fuchsin 11  parts. 

Aniline   water 100  parts. 

Absolute  alcohol 10  parts. 

Sections  are  left  for  twelve  hours  in  this  solution.  Treat  the  specimens 
with  l-to-3  solutions  of  nitric  acid  a  few  seconds;  wash  in  alcohol  (60  per 
cent.)  for  a  few  minutes;  after-stain  with  diluted  solution  of  vesuvin  or 
methylene-blue  for  a  few  minutes;  wash  again  in  60-per-cent.  alcohol;  de- 
hydrate in  absolute  alcohol;  clear  with  cedar-oil;  mount  in  Canada  balsam. 

Ziehl-Neelson  Metli.od. — Leave  the  sections  for  fifteen  minutes  in  carbol- 
fuchsin  solution;  decolorize  in  2-5-per-cent.  solution  sulphuric  or  nitric  acid; 
wash  in  6-per-cent.  alcohol;  immerse  in  a  saturated  aqueous  solution  of 
methylene-blue  for  double  stain;  wash,  dehydrate,  and  mount  in  balsam. 
The  examination  of  fluids  for  bacilli  can  be  done  rapidly  and  most  satis- 
factorily by  Gibbes'  method: — 

GIBBES'    MAGENTA  SOLUTION. 

Magenta    2  parts. 

Aniline  oil 3  parts. 

Alcohol   (specific   gravity,   0.830) 20  parts. 

Distilled  water 20  parts. 

Stain  cover-glass  preparations  in  this  solution  for  fifteen  or  twenty  min- 
utes; wash  in  l-to-3  solution  of  nitric  acid  until  the  color  is  removed;  rinse 
in  distilled  water;  after-stain  with  methylene-blue,  methyl^green,  iodine- 
green,  or  a  watery  solution  of  crysoidin,  five  minutes;  wash  in  distilled  water 
until  no  more  color  comes  away;  transfer  to  absolute  alcohol  for  five  min- 
utes; dry,  and  preserve  in  Canada  balsam. 

M.  Dorset  recommends  the  staining  of  cover-glass  preparations  made 
in  the  usual  way,  for  five  or  ten  minutes  in  a  cold,  saturated  solution  of 
Sudan  iii  in  80  per  cent,  of  alcohol,  and  then  to  wash  for  five  minutes  in 
70-per-cent.  alcohol.  Tubercle  bacilli  stained  in  this  manner  are  not  de- 
colorized after  remaining  in  4-per-cent.  solution  of  sulphuric,  nitric,  or  hy- 
drochloric acid  or  ammonia.  Sections  (fixed  in  alcohol  and  imbedded  in 
celloidin)  may  be  stained  in  the  same  manner,  and  then  counterstained  with 
methylene-blue,  dehydrated  in  absolute  alcohol,  and  cleaned  in  oil  of  cloves. 
Smegma  and  other  bacilli  are  not  stained  by  this  method.  Presumably 
the  procedure  depends  on  the  presence  of  fat  in  the  tubercle  bacilli;  and 
the  beaded  appearance  which  is  very  marked  in  the  sudan  preparations, 
probably  indicates  the  presence  of  fat-droplets  in  the  bacilli.  Sudan  is  a 
specific  stain  of  fat. 


482 


PKINCIPLES    OF    SUEGEEY. 


Cultivation. — The  best  culture-medmm  for  the  bacillus  of  tuberculosis 
is  solid,  sterilized  blood-serum  of  the  cow  or  sheep,  with  or  without  the 
addition  of  gelatin,  at  a  temperature  of  37°  to  38°  C.  (98.6°  to  100.4°  F.). 
The  bacillus  grows  very  slowly,  and  only  between  the  temperatures  of  30° 
and  41°  C.  (86°  and  105.8°  F.).  In  about  a  week  or  ten  days  the  culture 
appears  as  little  whitish  or  yellowish  scales  and  grains.  Cultivations  can  also 
be  made  in  a  glass  capsule  or  solid  blood-serum, 
and  the  appearance  of  the  growth  studied  under  the 
microscope.  The  scales  or  pellicles  are  then  seen 
to  be  made  up  of  colonies  of  a  perfectly  charac- 
teristic appearance.  The  growth  ceases  after  three 
or  four  weeks.  The  blood-serum  is  not  liquefied 
unless  putrefactive  bacteria  contaminate  the  cult- 
ure. Frankel  figures,  in  his  "Atlas  der  Bacterien- 
kunde,"  a  luxuriant  culture  of  the  bacillus  of  tuber- 
culosis upon  glycerin-agar. 

Kocard  and  Eoux  have  found  that  coagulated 
blood-serum  is  improved  for  the  growth  of  the  ba- 
cillus by  adding  peptone,  soda,  and  sugar.  A 
further  addition  of  6  to  8  per  cent,  of  glycerin 
favors  the  growth  of  the  bacillus  still  more,  while, 
at  the  same  time,  it  prevents  the  formation  of  a 
dry  crust  upon  the  culture-medium,  which  other- 
wise forms  by  evaporation.  They  also  made  suc- 
cessful cultivations  upon  agar-agar  bouillon,  to 
which  was  added  6  to  8  per  cent,  of  glycerin,  kept 
at  a  temperature  of  39°  C.  (102.2°  F.). 

Koch  has  cultures  3  years  old  which  have 
passed  through  40  generations  and  still  retain  their 
virulence,  showing  plainly  the  longevity  and  te- 
nacitv  of  the  bacillus  of  tuberculosis. 


% 


m 


'-WW 


ia.,ii;,t*W  PI 


INOCULATION    EXPEEIMENTS. 


Fig.  169.— Vegetations  of 
Tubercle  BaciUi  upon  Ster- 
ilized Blood-serum,  Twenty- 
six  Weeks  Old.  Natural 
Size.    (Baumgarten.) 


Long  before  the  discovery  of  the  bacillus  of 
tuberculosis  by  Koch  genuine  tuberculosis  was 
produced  artificially  in  animals  by  inoculation 
with  the  products  of  tubercular  inflammation.  Hueter  inoculated  the 
anterior  chamber  of  the  eye  in  rabbits  with  lupous  tissue,  and  produced 
typical  tuberculosis  of  the  iris.  Schllller  introduced  fragments  of  lupous 
tissue  directly  into  the  veins  of  animals,  and  in  this  way  caused  pulmo- 
nary tuberculosis.  Koch  produced  tuberculosis  in  animals  susceptible  to 
this  disease  by  implantation  of  tubercular  tissue  in  various  localities  and 


INOCULATION    EXPERIMENTS.  483 

by  inoculation  with  pure  cultures,  the  experiments  yielding,  almost  with- 
out exception,  positive  results.  The  same  author  inoculated  the  anterior 
chamber  of  the  eyes  in  18  rabbits  from  5  cases  of  lupus,  and  in  all  of  them 
tuberculosis  of  the  iris  was  produced,  and,  if  life  was  prolonged  for  a 
sufficient  length  of  time,  was  followed  by  tuberculosis  of  the  lymphatic 
glands  of  the  neck,  lungs,  kidneys,  liver,  and  spleen.  ,  Similar  results  were 
also  obtained  in  5  guinea-pigs.  Cornet  has  made  numerous  experiments, 
in  Koch's  laboratory,  on  animals,  to  ascertain  the  inoculability  of  tubercu- 
losis through  abrasions  of  the  skin,  or  a  pure  culture  of  tubercle  bacilli 
was  applied  to  a  cutaneous  abrasion;  the  result  in  most,  if  not  all,  cases 
is  a  local  tuberculosis  in  the  adjacent  lymphatic  glands,  and,  later,  a 
general  miliary  tuberculosis. 

The  same  author  made,  more  recently,  a  long  series  of  experiments 
on  dogs,  to  ascertain  the  different  avenues  through  which  tubercular  in- 
fection is  known  to  take  place.  Tubercular  sputum  and  pure  cultures  in- 
serted into  the  lower  conjunctival  sac  in  healthy  dogs  produced  tissue- 
hyperplasia  at  the  seat  of  inoculation,  and  was  followed  by  infection  of 
the  cervical  glands  on  the  corresponding  side.  Some  of  the  glands  under- 
went caseation,  and  the  presence  of  bacilli  could  be  demonstrated  in  all 
of  the  pathological  products.  In  other  animals  the  tubercular  material 
was  introduced  into  the  nasal  cavity.  The  cervical  glands,  especially 
those  on  the  corresponding  side,  became  enlarged  and  caseated.  Infection 
through  the  mouth,  by  depositing  the  tubercular  material  in  a  depression 
made  with  a  blunt  instrument  between  the  canine  teeth,  resulted  also 
in  tuberculosis  of  the  glands  of  the  neck.  Infection  of  the  external  meatus 
of  the  ear,  without  creating  an  infection-atrium  intentionally,  was  f ol- , 
lowed  by  infection  of  the  lymphatic  glands  behind  the  ear  and  along  the 
neck  on  the  same  side.  Cutaneous  tuberculosis  in  the  form  of  an  ulcer- 
ating lupus  was  produced  by  shaving  the  skin  on  one  side  of  the  nose 
and  face,  and  scratching  it  with  a  finger-nail  infected  with  a  pure  culture. 
Injection  of  pure  cultures  into  the  healthy  vagina  of  bitches  resulted  in 
local  tuberculosis  and  secondary  infection  of  the  inguinal  glands.  Inocu- 
lations of  other  parts  were  followed  by  the  same  train  of  symptoms:  local 
tuberculosis  at  the  seat  of  infection,  followed  by  dissemination  of  the 
process  along  the  course  of  lymphatic  channels.  The  lungs  were  found 
affected  only  in  two  of  the  animals.  These  experiments  show  conclusively 
that  the  bacillus  of  tuberculosis,  introduced  through  superficial  peripheral 
infection-atria,  seeks  the  lymphatic  channels,  through  which  it  is  ex- 
tensively disseminated  before  general  infection  takes  place.  Cornil  and 
Leloir  implanted  lupous  tissue  into  the  peritoneal  cavity  of  guinea-pigs, 
and  in  5  cases  out  of  14  experiments  produced  peritoneal  and  general 
tuberculosis.     Pagenstecher  and   Pfeiffer  took  the  secretion   of  the  con- 


484  PKINCIPLES    OF    SUEGEKY. 

junctiva  from  patients  suffering  from  lupus  of  this  structure^  and  injected 
it  into  the  anterior  chamber  of  the  eye  in  rabbits.  After  five  to  six  weeks 
nodules  could  be  seen  on  the  surface  of  the  iris,  which,  on  examination, 
were  found  to  be  in  every  respect  identical  with  tuberculosis  of  this  organ. 
Doutrelepont  inoculated  the  peritoneal  cavity  in  50  guinea-pigs,  and  in  8 
rabbits  the  anterior  chamber  of  the  eye  with  the  same  material,  with  the 
result  that  in  all  of  the  animals  local  tuberculosis  was  produced  at  the 
point  of  inoculation,  and  in  3  of  the  guinea-pigs  and  in  1  rabbit  the  local 
disease  was  followed  by  general  tuberculosis. 

Inoculations  with  material  from  so-called  scrofulous  glands  produce 
the  same  effect  as  when  lupous  tissue  is  used,  and  we  are,  therefore,  forced 
to  conclude  that  these  glands  owe  their  existence  to  the  same  cause. 
Arloing  prepared  an  emulsion  from  a  scrofulous  (tubercular)  gland, 
caseous  in  its  centre,  which  was  taken  from  a  boy  aged  14.  Thiswwas 
injected  beneath  the  skin  of  10  rabbits  and  the  same  number  of  guinea- 
pigs.  Visceral  tuberculosis  developed  in  all  of  the  guinea-pigs,  but  the 
rabbits  remained  healthy,  except  that  2  showed  yellow,  caseous  granula- 
tions at  the  seat  of  inoculation.  From  these  experiments  he  inferred  that 
scrofula  and  tuberculosis  were  nearly  allied  affections,  but  caused  by  different 
agents  or  they  were  derived  from  the  same  virus,  of  which  the  activity  was 
modified  in  the  scrofulous  form. 

That  the  number  of  bacilli  injected  has  a  great  deal  to  do  with  the 
result  has  been  satisfactorily  demonstrated  by  Bollinger.  He  found  that 
infectious  milk  from  a  tubercular  cow,  which  produced  local  tuberculosis 
by  intraperitoneal  injections,  lost  its  virulence  if  diluted  from  1  :  40  to 
1  :  100.  The  sputum  of  phthisical  patients  was  found  much  more  virulent, 
and  had  not  lost  its  power  to  produce  tuberculosis  on  being  diluted 
1  :  100,000,  on  being  injected  into  the  abdominal  cavity  or  the  subcu- 
taneous connective  tissue.  Feeding  experiments  with  sputum  diluted  1  :  8 
yielded  negative  results.  Pure  cultures  remained  virulent  when  diluted 
1  :  400,000.  All  the  experiments  proved  that  the  more  concentrated  the 
material  and  the  greater  the  number  of  bacilli,  the  more  rapid  and  in- 
tense was  the  development  of  the  lesion  caused  by  the  injection.  It  was 
estimated  that  about  820  bacilli  were  necessary  to  produce  tuberculosis  in 
guinea-pigs.  Intraperitoneal  injections  did  not  always  produce  peri- 
toneal tuberculosis,  and  in  cases  where  this  did  not  occur  the  organs 
affected  were  the  lymphatic  glands,  spleen,  lungs,  liver,  kidneys,  and 
genital  organs,  in  the  order  of  frequency  named,  showing  conclusively  that 
localization  does  not  invariably  take  place  at  the  point  of  primary  in- 
fection. 

Direct  intravenous  infection  by  injections  of  pure  cultures,  suspended 
in  distilled  water,  is  the  most  effective  way  in  which  diffuse  miliary  tuber- 


INOCIILATION-TUBEIICULOSIS    IN    MAN.  485 

culosis  can  be  artificially  produced  in  animals  with  unfailing  certainty. 
Koch  succeeded  also  in  producing  the  disease  in  rabbits,  guinea-pigs,  rats, 
and  white  mice,  by  inhalation.  A  pure  culture,  suspended  in  distilled 
water,  was  used  with  a  hand-spray,  and  the  cages  in  which  the  animals 
were  kept  were  filled  with  the  infected  spray.  The  animals  were  killed 
after  twenty-eight  days,  and  all  of  them  showed  unmistakable  signs  of 
pulmonary  tuberculosis. 

TOXINS    OP    THE    TUBERCLE    BACILLUS. 

The  tubercle  bacillus,  like  all  other  pathogenic  microbes,  when  active 
in  the  living  body  produces  toxins  on  which  its  pathogenic  action  on  the 
tissues  depends.  Maffuci  reports  the  results  of  many  experiments  relating 
to  the  toxic  products  of  the  tubercle  bacillus.  He  concludes  that  cultures 
of  tubercle  bacilli  in  which  the  bacilli  have  been  destroyed  contain  a  toxin 
which  is  resistant  to  time,  heat,  desiccation,  sunlight,  and  the  gastric  juice. 
This  toxin  is  derived  from  the  bacilli  and  is  set  free  by  their  disintegra- 
tion. It  is  not  the  product  of  secretion  of  the  bacilli,  nor  does  it  originate 
in  the  nutrient  medium.  This  poisonous  substance  is  very  potent,  a 
minute  dose  being  sufficient  to  cause  marasmus.  It  may  be  conveyed  from 
mother  to  foetus  without  the  transmission  of  the  bacillus,  and  can  cause 
abortion  or  premature  birth.  If  the  foetus  is  born  alive, 'marasmus  is  apt 
to  develop.  The  milk  may  also  contain  the  toxin.  When  concentrated, 
it  is  capable  of  causing  tubercular  abscesses.  Weak  solutions  produce 
circulatory  disturbances,  and  catarrhal  inflammations  are  apt  to  occur: 
processes  which  have  a  distinctive  effect  on  the  red  corpuscles.  In  chronic 
tubercular  processes  the  elimination  of  the  toxin  may  cause  parenchyma- 
tous nephritis  or  fatty  degeneration  of  the  epithelium  of  the  glomeruli. 
Some  of  the  most  efficient  antitubercular  agents  prove  curative  by  neu- 
tralizing the  toxin  without  destroying  the  bacillus.  Among  these  iodo- 
form and  guaiacol  are  noted  examples. 

INOCULATION-TUBERCULOSIS    IN    MAN. 

The  opinion  that  tubercle  is  capable  of  inoculation  was  held  by 
ancient  writers,  and  Laennec  himself,  after  a  nick  from  a  saw  while 
making  a  necropsy  on  a  phthisical  subject,  thought  that  he  witnessed  an 
example  of  inoculation  in  a  small  tubercle  that  developed  in  the  injured 
skin,  but  twenty  years  afterward  this  distinguished  clinician  was  in  good 
health,  though  finally  he  died  of  phthisis. 

Schmidt  made  a  number  of  experiments  to  ascertain  the  efHect  of 
inoculations  of  superficial  abrasions  of  the  skin  with  the  virus  of  tuber- 
culosis. In  guinea-pigs  he  made  abrasions  in  the  skin,  to  which  he  applied 
tubercular  material  and  covered  the  point  of  inoculation  with  collodium. 


486  PRINCIPLES    OF    SUEGEEY. 

All  of  his  experiments  failed  in  producing  tuberculosis,  while  in  the  con- 
trol animals,  in  which  the  infectious  material  was  introduced  into  the 
subcutaneous  tissue,  or  into  the  peritoneal  cavity,  tuberculosis  developed 
without  a  single  exception.  He  believes  that  the  results  of  these  experi- 
ments are  only  corroborative  of  the  assertion  previously  made  by  Bol- 
linger and  Koch,  that  the  susceptibility  of  the  cutis  for  tubercular  infec- 
tion is  slight.  A  sufficient  number  of  authenticated  cases,  however,  have 
been  reported,  during  the  last  few  years,  to  prove  that  in  man  tuberculosis 
is  not  infrequently  contracted  by  the  absorption  of  tubercular  material 
through  small  wounds  and  superficial  abrasions  of  the  skin.  Volkmann, 
a  number  of  years  ago,  made  the  statement  that  tubercular  infection 
never  takes  place  through  a  large  operation  wound,  or  at  the  site  of  severe 
injuries,  but  that  localization  of  the  bacillus  is  likely  to  take  place  in  parts 
the  seat  of  very  slight  contusions,  or  what  may  appear  at  the  time  as  an 
insignificant  injury.  He  explained  this  by  assuming  that  the  active  tissue- 
changes  which  take  place  during  the  process  of  regeneration  after  a  severe 
trauma  prevent  the  infection. 

In  studying  the  cases  of  inoculation-tuberculosis,  which  will  be  re- 
ferred to  below,  it  will  be  seen  that  the  infection-atrium  was  always  caused 
by  a  trivial  injury.  A  very  interesting  case  of  inoculation-tuberculosis 
came  under  my  own  observation  a  few  years  ago.  The  patient  was  a 
strong,  healthy  young  woman,  with  a  good  family  history,  who  was  em- 
ployed in  a  rag  establishment  in  sorting  rags.  Two  months  before  she 
came  under  my  care  she  noticed  a  small  sore  on  the  dorsal  side  of  the 
right  index  finger,  near  the  metacarpo-phalangeal  joint.  The  place  ulcer- 
ated, and  the  granulation-tissue  which  appeared'  melted  rapidly  away, 
forming  a  deep  excavation,  which  had  the  extensor  tendon  for  its  floor. 
Two  weeks  later  a  nodule  appeared  in  the  course  of  the  lymphatic  vessels, 
near  the  elbow-joint,  over  the  anterior  aspect  of  the  arm,  which  was  soon 
followed  by  the  formation  of  three  other  nodules  between  this  point  and 
the  primary  seat  of  infection.  General  health  not  impaired  in  the  least. 
Inflamed  foci  neither  painful  nor  tender  on  pressure;  presented  distinct 
evidences  of  fluctuation.  All  the  foci  were  excised,  and  presented  the 
characteristic  appearances  of  tubercular  tissue.  The  primary  focus,  after 
excision,  left  such  a  large  defect  that  it  was  found  impossible  to  close  the 
wound  by  suturing,  and  consequently  the  surface  was  covered  with 
Thiersch  grafts  taken  from  the  arm.  Primary  union  of  all  the  sutured 
wounds  and  speedy,  deflnitive  healing  of  the  defect  at  the  primary  seat  of 
infection. 

There  can  be  no  doubt  whatever  that  in  this  case  infection  occurred 
through  a  small  wound  of  the  index  finger,  by  handling  contaminated 
rags,   which   was   followed   by   dissemination   of   the   bacilli   through   the 


INOCULATION-TUBERCULOSIS    IN    MAN. 


487 


lymphatic  vessels  in  direct  communication  with  the  primary  infection- 
atrium.  I  have  had  also  under  treatment  a  well-marked  case  of  extensive 
subcutaneous  tuberculosis  of  the  hand,  in  the  person  of  the  mother  of 
several  children  Avho  died  of  pulmonary  tuberculosis.  The  disease  orig- 
inated near  the  tip  of  the  index  finger,  at  the  site  of  a  former  abrasion, 
in  which  a  papillomatous  swelling  formed.  This  ulcerated  and  healed 
partly,  when  the  disease  commenced  to  spread  along  the  subcutaneous 
connective  tissue,  and  when  the  patient  came  under  my  observation  it  had 
extended  almost  over  the  entire  dorsum  of  the  hand.  A  number  of  fistu- 
lous openings  existed,  which  discharged  daily  only  a  few  drops  of  thin, 
serous  pus.  The  subcutaneous  tissue  was  transformed  into  a  mass  of 
granulation-tissue,  which  was  removed  with  a  small  spoon  through 
multiple  incisions,  and  the  wound  surfaces  were  freely  iodoformized.    The 


Fig.  170.- 


-Inoculation-tuberculosis.     Primary  infection  at  the  base  of  the  thumb-nail, 
secondary  infection  through  lymphatics  of  forearm. 


process  of  repair  was  slow,  but  satisfactory.  Martin  du  Magny  has  col- 
lected the  clinical  material  of  cases  of  inoculation-tuberculosis,  and  in  his 
comments  upon  the  cases  asserts  that  the  sputum  of  phthisical  patients 
and  animal  excretions  were  the  usual  carriers  of  the  bacilli;  consequently 
the  affection  is  most  frequently  met  with  among  physicians,  nurses, 
butchers,  and  teamsters.  The  external  appearances,  manifested  at  the 
point  of  inoculation,  consist  in  the  formation  of  a  red  nodule  in  the  skin, 
which  increases  slowly  in  size  and  forms  miliary  abscesses,  in  which  papil- 
lomatous proliferation  takes  place,  and  around  which  a  new  zone  of  in- 
filtration forms,  which,  in  turn,  again  suppurates  and  becomes  papilloma- 
tous. The  centre  heals  with  the  formation  of  a  flat  cicatrix,  while  the 
destructive  process  progresses  slowly  in  a  peripheral  direction. 

Hanot  has  collected  6  cases,  1  of  which  came  under  his  own  observa- 


488  PRINCIPLES    OF    SURGERY. 

tion.  In  this  case  the  patient  was  in  the  third  stage  of  phthisis,  and  died 
soon  after  from  a  tuhercular  ulcer  on  the  arm  of  at  least  two  years'  stand- 
ing, while  the  history  of  cough  only  dated  from  the  last  two  months,  which 
would  show  that  the  cutaneous  lesion  preceded  the  pulmonary  affection,  and 
was  the  cause  of  the  phthisis.^  In  the  cases  which  he  collected  the  sources 
of  inoculation  were  necropsies  on  tubercular  patients,  handling  old  bones, 
pricking  the  hand  with  a  fragment  of  porcelain  from  the  broken  spittoon 
used  by  a  phthisical  patient,  and  in  4  of  the  cases  the  tubercular  character 
of  the  cutaneous  lesion  was  verified  by  finding  the  bacilli. 

Eiselsberg  has  observed  4  cases  of  inoculation-tuberculosis  during 
the  last  few  years.  The  first  case  was  a  girl  16  years  old,  in  whom  the 
disease  developed  in  the  track  of  a  perforation  of  the  lobe  of  the  ear 
made  preparatory  to  the  wearing  of  an  ear-ring,  and  which  was  kept  from 
closing  by  the  insertion  of  a  thread.  The  tubercular  product  appeared 
in  the  shape  of  a  hard  swelling  the  size  of  a  hazel-nut.  The  second  case 
was  a  young  man  who  injured  himself  with  the  point  of  a  knife  above  the 
external  epicondyle  of  the  humerus.  Eighteen  days  later  a  swelling,  the 
size  of  a  pea,  appeared  at  the  site  of  injury,  with  an  ulcerated  surface 
covered  by  pale,  flabby  granulations.  In  the  axilla  of  the  same  side  one 
of  the  lymphatic  glands  was  found  enlarged  to  the  size  of  a  hazel-nut. 
The  third  case  concerned  a  woman  50  years  of  age,  who  was  supposed 
to  have  infected  herself  by  washing  the  clothes  of  a  person  the  subject  of 
a  tubercular  abscess  of  the  spine,  and  who  with  her  fingers  scratched  an 
acne  pustule  on  her  face.  At  this  point,  six  to  eight  days  later,  a  pain- 
ful swelling,  the  size  of  a  pea,  formed,  which  subsequently  became  in- 
durated, and  opened  spontaneously  in  six  weeks.  At  the  end  of  three 
months  the  place  of  inoculation  presented  an  ulcer  with  indurated  margins. 
In  the  fourth  case  the  inoculation  followed  in  the  track  made  by  the  needle 
of  an  hypodermic  syringe,  in  a  girl  20  years  of  age.  The  swelling  which 
appeared  opened  after  six  weeks,  and  a  small  quantity  of  pus  was  dis- 
charged. Four  months  subsequently  the  fistulous  opening  communicated 
with  an  abscess-cavity,  the  size  of  a  silver  dollar,  lined  by  a  wall  of  granu- 
lation-tissue. In  all  of  these  cases  no  evidence  of  tuberculosis  could  be 
detected  in  any  of  the  internal  organs,  and  the  local  disease  could  be 
traced  in  every  instance  to  some  antecedent  lesion,  through  which  the 
infection  had  evidently  taken  place.  The  diagnosis  in  all  cases  was  based 
on  an  examination  of  the  granulation-tissue  for  the  bacillus  of  tubercu- 
losis, which  was  always  found  present. 

Another  case  of  tubercular  infection  through  ear-rings  is  related 
from  Vienna  in  a  girl,  14  years  of  age,  of  a  perfectly  healthy  family,  who 
wore  ear-rings  left  to  her  by  a  friend  who  had  died  of  pulmonary  tuber- 
culosis.   Soon  ulcers  appeared  on  the  lobes  of  both  ears,  the  cervical  glands 


INOCULATION-TUBEKCULOSIS    IN    MAN.  489 

became  swollen,  and  percussion  and  auscultation  revealed  infiltration  of 
the  apex  of  the  left  lung.  Tubercle  bacilli  were  found  in  the  ulcers  and 
sputa.  This  case  is  only  another  instance  of  inoculation-tuberculosis, 
where,  from  the  point  of  infection,  the  disease  extended  along  the  lym- 
phatic system,  and,  finally,  systemic  infection  from  the  entrance  of  bacilli 
into  the  general  circulation. 

In  the  cases  of  inoculation-tuberculosis  cited  above,  infection  oc- 
curred through  some  slight  lesion,  puncture,  or  abrasion,  which  furnished 
the  necessary  infection-atrium  for  the  entrance  of  the  bacillus  into  the 
tissues,  but  a  number  of  cases  have  been  reported  by  reliable  observers 
where  infection  took  place  through  a  larger  wound  or  granulation  surface. 
Middeldorpf  reports  the  case  of  a  healthy  carpenter,  who  opened  his  knee- 
joint  by  the  cut  of  an  ax,  and  dressed  the  wound  with  a  soiled  hand- 
kerchief. The  wound  healed  kindly,  but  later  the  joint  became  swollen, 
tender,  and  painful.  Resection  was  performed,  and  on  examining  the 
capsule  it  was  found  very  much  thickened.  In  the  granulation-tissue 
tubercle  bacilli  were  found.  Wahl  amputated  the  arm  of  a  boy  suffering 
from  gangrene,  the  result  of  an  injury,  and  discharged  the  patient  with 
the  wound  completely  healed,  except  a  small  granulation  surface  from 
which  the  drainage-tube  had  been  removed.  At  first  the  wound  was 
dressed  by  a  girl  suffering  from  tuberculosis.  The  wound  soon  showed 
all  the  characteristic  appearances  of  fungous  disease,  and  the  lymphatic 
glands  became  infected  from  this  source.  I  have  seen  in  numerous  in- 
stances large  wounds  made  for  the  removal  of  tubercular  glands  become 
infected  a  week  or  two  after  the  operation,  after  the  superficial  wound 
had  apparently  healed.  In  such  cases  the  overlying  cicatrix  is  subse- 
quently completely  destroyed  by  the  granulations  underneath.  The  ener- 
getic use  of  the  sharp  spoon  and  free  iodoformization  are  the  only  re- 
sources in  finally  effecting  the  healing  of  such  wounds.  Konig  has  seen 
16  cases  of  inoculation-tuberculosis,  following  operations  for  tubercular 
disease  of  bones  and  joints,  and  2  such  cases  have  been  described  by 
Kraske.  Czerny  reports  2  cases  in  which  tuberculosis  followed  in  wounds 
treated  by  Eeverdin's  method  of  skin-grafting.  In  both  instances  the  pa- 
tients were  healthy,  and  the  skin-transplantation  was  made  during  the 
treatment  of  extensive  burns.  The  skin  was  taken  from  limbs  amputated 
for  tubercular  afEections.  In  both  cases  tuberculosis  of  the  adjacent  joint 
occurred,  and  in  1  of  them  tuberculosis  of  the  granulating  surface.  A 
number  of  cases  of  inoculation-tuberculosis  following  circumcision  are  on 
record,  in  which  the  infection  often  occurred  in  the  practice  of  orthodox 
Jews,  who  performed  the  operation  in  accordance  with  the  directions  laid 
down  in  the  Mosaic  laws.  The  loose  connective  tissue  of  the  prepuce,  richly 
supplied  with  lymphatics,  is  an  admirable  surface  for  absorption,  and. 


490  PRINCIPLES    OF    SUEGERY. 

when  infectious  material  is  brought  in  contact  with  it,  furnishes  the  most 
favorable  conditions  for  the  production  of  local  lesions  and  the  transporta- 
tion of  microbes  along  the  lymphatic  channels  to  more  distant  parts. 

Lehmann  has  observed  10  cases  of  inoculation-tuberculosis  in  Jewish 
boys,  caused  by  sucking  the  wound  after  ritual  circumcision  by  a  phthisical 
person.  Ten  days  after  the  circumcision  the  wound  became  the  seat  of 
ulceration,  and  the  inguinal  glands  began  to  enlarge.  Four  of  the  children 
died  of  tubercular  meningitis,  and  3  died  after  a  prolonged  illness  caused 
by  multiple  tubercular  abscesses.  Hofmokl  has  reported  a  similar  case, 
and  Weichselbaum  detected  the  bacillus  of  tuberculosis  in  the  circum- 
cision wound. 

Elsenberg  has  described  3  cases  of  tubercular  infection  after  circum- 
cision. All  the  cases  were  infants,  and  the  disease  appeared  primarily  in 
the  wound  or  cicatrix,  and,  later,  in  the  inguinal  glands.  Local  treatment 
by  scraping  proved  successful.  The  diagnosis  was  corroborated  by  micro- 
scopical examinations  of  the  granulation-tissue.  Willy  Meyer  relates  a 
case  in  which  circumcision  was  performed  according  to  the  rules  of  the 
Jewish  Church  eight  days  after  birth  by  an  old  man,  and  in  which  four 
weeks  after  the  ceremony  an  induration  appeared  at  the  frenulum,  and 
the  inguinal  glands  about  the  same  time  began  to  enlarge.  Syphilis  was 
suspected,  and  the  little  patient  was  put  on  a  specific  course  of  treatment. 
The  inguinal  glands  suppurated,  and  another  small  abscess  formed  in  the 
right  gluteal  region.  The  diseased  tissue  about  the  glans  penis  was  then 
excised.  Microscopical  examination  of  the  granulations  revealed  the  pres- 
ence of  miliary  tubercles  and  bacilli  in  great  abundance.  The  above  cases 
furnish  abundant  and  convincing  proof  of  the  possibility  of  the  trans- 
mission of  tuberculosis  by  cutaneous  inoculation  through  superficial  abra- 
sions, small  wounds,  and  granulating  surfaces,  and  this  subject  is  deserving 
of  the  most  careful  attention  of  surgeons  in  the  matter  of  prophylaxis, 
diagnosis,  and  treatment. 

HISTOLOGY    OF    TUBERCLE. 

A  tubercle-nodule  is  an  aggregation  of  cells  primarily  invisible  to 
the  naked  eye,  the  product  of  a  minute  focus  of  infiammation,  caused 
by  the  presence  of  the  essential  cause  of  tuberculosis.  When  the  nodule  be- 
comes so  large  that  it  can  be  recognized  without  the  aid  of  the  microscope, 
it  already  consists  of  a  confluence  of  a  number  of  minute  microscopical 
nodules.  Laennec  described  four  varieties  of  tubercle:  1.  Miliary  tubercle, 
where  the  visible  product  of  tubercular  inflammation  appears  as  nodules 
the  size  of  a  millet-seed,  of  a  grayish  color,  and  usually  arranged  in  groups. 
2.  Crude  tubercle,  where  the  miliary  nodules  have  become  confluent  and 
have  undergone  caseous  degeneration.     3.  Granular  tubercle,  where  the 


HISTOLOGY    OF    TUBERCLE.  491 

nodules  are  extremely  small,  nearly  the  size  of  a  millet-seed,  and  scattered 
uniformly  through  a  whole  organ.  They  are  not  arranged  in  groups  and 
have  no  tendency  to  become  confluent.  In  the  centre  they  become  trans- 
formed into  yellow  tubercle.  4.  Encysted  tubercles,  or  such  as  are  consti- 
tuted of  a  hard  mass  of  crude  tubercle  in  the  centre  surrounded  by  a  firm 
fibrous  capsule.  These  varieties  only  represent  different  phases  of  the 
same  process  and  different  stages  of  inflammation  produced  by  the  same 
cause.  The  anatomico-pathological  basis  of  tubercle  was  created  by  Vir- 
chow,  and  has  been  firmly  established  through  the  laborious  researches 
of  Langhans,  Wagner,  Klebs,  Schueppel,  Eindfleisch,  Koester,  Friedlander, 
Fox,  Baumgarten,  and  many  others.  The  specific-cell  theory  has  had 
many  able  advocates,  and  has  been  the  subject  of  many  animated  discus- 
sions, but  it  has  at  last  been  abandoned  as  fallacious  and  unscientific. 
There  are  no  specific  tubercle-cells. 

Lebert's  tubercle-corpuscle  is  a  thing  of  the  past,  and  is  only  referred 
to  as  a  landmark  in  the  history  of  tuberculosis.  Eeinhart  showed  that 
these  cells,  which  were  regarded  by  Lebert  as  characteristic  and  pathogno- 
monic of  tubercle,  could  be  found  in  all  products  of  chronic  inflammation, 
and  their  presence  was  only  an  evidence  that  a  certain  amount  of  inflam- 
mation existed.  When  we  speak  of  a  tubercle,  we  mean  a  nodule  or 
granule,  which  is  composed  of  leucocytes  derived  from  the  capillary  vessels 
damaged  by  the  bacillus  of  tuberculosis,  or  new  cells  derived  from  tissue- 
proliferation  of  preexisting  cells  acted  upon  by  the  same  cause.  The 
anatomical  character  of  the  nodule  consists,  not  in  the  presence  of  any 
particular  cell-element,  but  in  the  peculiar  arrangement  of  the  cells;  and 
this  feature  is  the  only  reliable  anatomical  guide  in  making  a  diagnosis 
by  the  use  of  the  microscope.  The  product  of  tubercular  inflammation 
occurs  either  in  the  form  of  submiliary,  microscopical  granules,  visible 
miliary  nodules,  or  a  cheesy  infiltration,  which  may  occupy  an  entire 
organ,  as  a  lymphatic  gland,  or  large,  isolated  foci,  as  in  bone.  Every 
tubercular  product  commences  as  submiliary  nodules,  which,  when  they 
become  confluent,  are  transformed  into  visible  gray  miliary  nodules,  which 
again  coalesce  after  they  have  undergone  caseous  degeneration;  form  cheesy 
masses,  which  may  be  either  small  and  circumscribed  or  large  and  diffuse. 

Virchow  defines  tubercle  as  a  nodule  '  representing  a  heterogeneous 
growth:  a  product  originally  necessarily  of  a  cellular  nature,  taking  its 
starting-point  from  the  connective  tissue  or  from  other  mesoblastic  struct- 
ure, as  marrow,  fat,  or  bone.  He  asserts  that  the  microscopical  or  sub- 
miliary granule  contains  all  of  the  essential  histological  elements  of 
tubercle,  and  by  aggregation  forifis  the  ordinary  miliary  nodule  of  Laen- 
nec.  When  the  nodules  become  confluent  they  may  form  masses  the  size 
of  a  walnut,  surrounded  by  a  common  zone  of  embryonal  tissue.     The 


492,  PKINCIPLES    OF    SUEGEEY. 

yellow  tubercle^,  the  crude  tubercle  of  Laennec,  is  a  more  advanced  stage 
of  the  gray,  the  histological  elements  of  the  latter  having  undergone 
caseation. 

HISTOGENESIS    OF    TUBEECLE. 

Schick  endeavored  to  end  the  dispute  still  existing  between  the 
school  of  Metschnikoff  and  that  of  Baumgarten  relative  to  the  part  taken 
by  the  fixed  tissue-cells  in  the  formation  of  tubercle.  The  former,  as  is 
well  known,  referred  all  cellular  elements  of  the  tubercular  inflammatory 
product  to  the  leucocytes,  while  the  latter  holds  that  they  originate  chiefly 
from  the  fixed  cells,  leucocytic  infiltration  occurring  later  as  a  secondary 
feature.  He  confirms  Baumgarten^s  views  of  the  participation  of  the 
fixed  cells  by  his  own  investigations  and  asserts  that  the  number  of  leuco- 
cytes depends  on  the  character  of  the  region  of  inoculation,  and  the  quan- 
tity and  quality  of  the  bacilli.  As  in  Baumgarten's  experiments  the  eyes 
of  the  inoculated  rabbits  were  constantly  kept  under  the  influence  of 
atropia,  which  retards  leucocytic  immigration,  that  observer  necessarily 
obtained  different  results  regarding  the  participation  of  the  white  cor- 
puscles. In  studying  the  histology  of  tubercle-tissue  the  unprejudiced 
student  will  find  that  the  preexisting  tissue  takes  the  first  and  most  im- 
portant part  in  the  formation  of  the  infiammatory  product,  but  the  leuco- 
cytes constitute  an  important  element  in  the  histogenesis  of  the  nodules, 
particularly  in  its  periphery. 

Colberg  asserts  that  tubercles  in  the  lungs  originate  from  the  nuclei 
of  the  capillary  vessels  and  the  connective  tissue,  the  epithelial  cells 
lining  the  alveoli  never  being  primarily  affected.  Bastian  observed 
tubercle-nodules  upon  the  small  vessels  in  cases  of  basilar  meningitis, 
but  refers  their  origin,  not  to  proliferation  of  the  nuclei  of  the  endothelial 
lining  of  the  vessels,  but  to  new  cells  springing  from  the  endothelial  cells 
of  the  perivascular  lymphatic  sheaths  which  surround  the  vessels  of  the 
meninges  of  the  brain. 

Knauff  demonstrated  the  lymphoid  character  of  the  adventitia  by 
examining  the  capillary  vessels  of  the  visceral  pleura  in  dogs  which  had 
been  exposed  for  a  long  time  to  an  atmosphere  impregnated  with  coal- 
dust.  He  found  the  pigment  lodged  in  small  masses  close  to  the  walls 
of  small  arteries  and  veins.  Examining  the  same  vessels  in  other  dogs 
not  thus  treated,  he  found  upon  the  outer  surface  of  the  adventitia  opaque, 
whitish-gray  nodules,  surrounded  by  round  and  oval  cells  containing 
nuclei,  also  lymph-corpuscles.  The  same  structures,  which  he  named 
lymph-nodules,  are  also  found  around  the  same  vessels  of  the  pleura  in 
man,  and  Knauff  looks  upon  these  lymphoid  structures  as  the  starting- 
point  of  tubercular  inflammation. 


HISTOGENESIS    OF    TUBEECLE.  493 

Klebs  maintains  that  the  endothelial  cells  of  lymphatic  vessels  are 
the  most  frequent  location  for  the  formation  of  the  primary  tubercle- 
nodule.  He  observed  that  in  cases  of  tubercular  ulceration  of  the  intes- 
tines the  peritoneum  is  reached  through  the  lymphatic  vessels.  Silver- 
stained  preparations  of  inoculation-tuberculosis  in  rabbits  showed  that 
the  most  recent  products  occurred  in  the  interior  of  the  lymphatic  vessels 
at  points  of  intersection.  In  some  places  the  nodules  extended  into  the 
tissues  between  the  lymphatic  vessels,  but  their  centre  always  corre- 
sponded to  the  location  of  a  lymphatic  vessel.  At  some  points  the  nodules 
were  seen  to  branch  out,  but  these  projections,  in  reality,  were  within  the 
lymphatic  vessels,  as  the  net-work  of  lymphatic  endothelia  could  be  seen 
above  and  underneath  the  tubercular  product.  Toward  the  centre  of  the 
nodule  no  endothelial  cells  could  be  distinguished,  and  this  fact  led  him 
to  the  belief  that  the  endothelial  cells  are  directly  concerned  in  the  pro- 
duction of  the  new  tissue.  In  the  mesentery  he  saw  the  tubercles  adhere 
to  the  outer  wall  of  the  capillary  vessels,  and,  as  the  spindle-shaped  cells 
of  the  outer  coat  appeared  to  be  pushed  apart  by  the  new  tissue,  he 
regards  the  adventitia  as  a  genuine  lymphoid  structure.  Eindfieisch  traces 
the  beginning  of  the  process  in  miliary  tuberculosis  of  the  lungs  to  a 
proliferation  of  the  endothelia  and  the  external  connective-tissue  layer  of 
the  capillary  lymphatic  vessels.  Edward  Smith  believes  in  the  epithelial 
origin  of  tubercle.  Manz  studied  the  development  of  tubercle  in  the 
choroid  in  patients  suffering  from  general  miliary  tuberculosis.  So  con- 
stantly does  this  disease  show  itself  in  this  structure  that  von  Graefe, 
Cohnheim,  Frankel,  and  Bouchut  recommend  ophthalmoscopic  examina- 
tion as  a  diagnostic  measure  in  cases  of  suspected  pulmonary  or  general 
tuberculosis.  Manz  traces  the  commencement  of  the  disease  in  the  cho- 
roid to  cell-pullulation  in  the  tunica  adventitia  of  the  small  vessels.  The 
process  is,  however,  not  limited  to  this  structure;  the  non-pigmented 
stroma-cells  may  also  assist  in  furnishing  material  for  the  new  product. 
Barth,  on  the  other  hand,  asserts  that  the  vessels,  in  cases  of  tuberculosis 
of  the  choroid,  are  not  primarily  affected;  according  to  his  observations, 
the  process  depends  exclusively  on  a  degeneration  of  the  stroma-cells,  as  the 
remaining  tissue  did  not  appear  affected. 

Cohnheim,  Ziegler,  and  others  maintain  that  the  leucocytes  furnish 
most  of  the  material  in  the  building  up  of  the  tubercle-nodule. 

Experiments  on  animals,  as  well  as  microscopic  examinations  of 
pathological  specimens,  have  sufficiently  demonstrated  the  fact  that  the 
tubercle-nodule  is  nothing  more  nor  less  than  a  circumscribed  inflamma- 
tory product,  the  histological  elements  of  which  are  composed  of  new^ 
tissue,  formed  by  proliferation  of  fixed  tissue-cells  which  have  come  in 
contact  with  the  bacillus  of  tuberculosis  or  its  toxins.     The  specific  pa- 


494  PRINCIPLES    OF    SUBGERY. 

thogenic  effect  of  the  bacillus  consists  in  its  power  to  cause  a  chronic 
inflammation  of  the  tissues  in  which  it  has  localized  or  with  which  it  has 
heen  brought  in  contact.  The  tissues  affected  are  the  cells  which  are 
nearest  the  essential  microbic  cause,  irrespective  of  their  embryological 
origin,  their  histological  structure,  or  physiological  function.  In  cases 
of  inoculation-tuberculosis  the  primary  nodule  develops  at  the  point  of 
insertion  of  the  virus  from  connective-tissue  proliferation,  and  from  here 
the  bacilli  enter  the  lymphatic  channels,  and  the  secondary  nodules  are 
composed  of  cells  derived  from  the  endothelial,  lymphoid,  and  connective- 
tissue  cells  which  compose  these  structures.  If  the  bacilli  are  injected 
in  sufflcient  quantity  directly  into  the  circulation  or  gain  entrance  into 
the  blood-current  from  some  tubercular  focus,  they  become  implanted 
upon  the  wall  of  distant  capillary  vessels,  and  the  nodule  which  forms  at 
the  seat  of  implantation  consists  of  cellular  elements  formed  by  the  tis- 
sues of  the  vessel-wall.  As  soon,  however,  as  bacilli  reach  the  extra- 
vascular  tissues,  they,  in  turn,  furnish  their  part  of  the  material  for  the 
further  growth  of  the  nodule.  If  the  tubercle  bacillus  becomes  implanted 
upon  a  mucous  surface,  as  the  bladder,  intestines,  nose,  larynx,  uterus, 
etc.,  if  such  surface  is  susceptible  to  tubercular  infection,  the  epithelial 
cells  take  an  early  and  active  part  in  the  inflammatory  process.  From 
the  manner  of  entrance  into  and  diffusion  through  the  tissues,  it  is  ap- 
parent that  the  mesoblastic  tissues,  the  connective-tissue  and  endothelial 
cells,  being  the  flrst  to  become  infected,  furnish  the  greatest  amount  of 
material  in  most  tubercular  lesions;  but  all  tissues,  when  infected,  take 
part  in  the  process. 

HISTOLOGICAL    STRUCTURE   OF   TUBERCLE. 

The  essential  histological  elements  which  make  up  a  primary  tubercle 
nodule  are:  (a)  leucocytes;  (h)  giant  cells;  (c)  epithelioid  cells;  (d)  reticu- 
lum. 

Leucocytes. — One  of  the  convincing  proofs  of  the  inflammatory  nature 
of  tuberculosis  is  the  presence  of  leucocytes  in  the  tubercle-nodule.  The 
bacillus  of  tuberculosis  appears  to  exercise  only  a  mild  pathogenic  effect 
on  the  capillary  wall,  and  the  primary  inflammatory  product  is  always 
scanty.  As  the  colorless  blood-corpuscle  can  only  escape,  in  considerable 
number,  through  inflamed  capillary  walls  which  have  undergone  alteration 
from  the  action  of  some  specific  microbic  cause,  it  is  evident  that  its 
migration  into  the  paravascular  tissues,  where  it  forms  a  part  of  the 
tubercular  product,  can  only  occur  after  such  alteration  has  taken  place 
from  the  action  of  the  bacillus  upon  the  cement-substance  of  the  endo- 
thelial lining  of  the  capillary  vessels.  The  leucocytes  are  found  scattered 
among  the  cellular  elements,  and  are  found  in  greatest  abundance  toward 


HISTOLOGICAL    STRUCTURE    OF    TUBERCLE.  495 

the  periphery  of  the  nodule.  (Fig.  172.)  The  leucocytes  invariably 
undergo  degenerative  changes,  and  are  never  k-ansformed  into  other 
forms  of  cells  found  in  the  tubercular  product.  They  have  been  described 
as  lymphoid  corpuscles.  Although  constantly  present,  they  are  most 
numerous  when  the  process  is  acute. 

Giant  Cells. — A  great  deal  has  been  said  and  written  concerning  the 
origin  and  diagnostic  value  of  the  giant  cells  in  the  tubercle-nodule. 
They  resemble  the  giant  cells  found  in  some  forms  of  sarcoma,  and  appear 
to  be  simply  certain  cells  which  have  outgrown  others  by  taking  up  a  greater 
amount  of  nourishment  in  the  shape  of  leucocytes  which  have  undergone 
fragmentation. 

The  giant  cells,  or,  as  Klebs  calls  them,  macrocytes,  arc  finely  granular. 


\  B 


Fig.  171.— A  Lupous  Nodule  Situated  Deeply  in  the  Corium.  The  specimen  is  inter- 
esting because  of  the  great  number,  size,  and  characteristics  of  the  giant  cells.  A,  con- 
nective tissue  of  corium;  B,  giant  cell;  C,  small,  round-cell  infiltration.  (Stained  by 
polychrome  methylene-blue.) 

and  contain  multiple  nuclei,  which  usually  occupy  the  periphery  of  the  cell, 
or  are  arranged  in  a  crescent  at  one  end.  In  tubercular  lesions  artificially 
produced  in  animals  the  giant  cells  contain  numerous  bacilli,  which  occupy, 
as  a  rule,  the  peripheral  zone  of  the  cells.  In  tuberculosis  in  man  the  bacilli 
in  these  cells  are  never  so  numerous,  and  as  central  degeneration  of  the  cells 
appears  they  disappear  in  this  portion  of  the  cell,  while  some  may  still  be 
found  in  the  periphery.  During  the  progress  of  the  disease  the  giant  cell 
becomes  more  and  more  fibrous  toward  the  periphery,  at  the  expense  of  the 
protoplasmic  part  in  the  centre.  The  protoplasm  evidently  is  transformed 
into  or  secretes  the  fibrous  margin.     If  caseation  does  not  take  place  the 


496 


PKINCIPLES    OF    SUEGERY. 


bacilli  disappear,  and  the  whole  cell-mass,  including  the  giant  cells,  is  con- 
verted into  a  cicatricial  mass. 

The  first  evidences  of  degeneration  appear  in  the  centre  of  the  giant 
cells,  and,  according  to  Weigert,  they  consist  of  structural  and  chemical 
changes  which  are  indicative  of  coagulation-necrosis. 

In  a  recent  tubercle-nodule  the  giant  cells  occupy  the  central  portion, 
around  which  the  epithelioid  cells  and  leucocytes  are  arranged.  The  vacu- 
oles are  necrotic  foci  within  the  cells. 

The  giant  cell  found  in  tubercular  tissue  has  its  prototype  in  normal 
tissue.  Giant  cells  were  first  discovered  in  normal  tissue  (marrow  of  bone) 
by  Eobin,  who  called  them  my elo plaques.  They  were  subsequently  accurately 
described  by  Virchow.    In  a  normal  condition  they  are  constantly  found  in 


Fig.  172. — Tubercle-nodule  in  Lymphatic  Gland.    A,  multinuclear  giant  cell;    B, 
epithelioid  cells;    0,  leucocytes  and  lymphoid  corpuscles.     X  500. 

bone  and  the  placenta.  They  are  also  found  occasionally  in  fat-tissue,  espe- 
cially in  cases  of  rapid  emaciation.  Kundrat  has  found  them  in  inflamed 
serous  membranes,  and  Strieker  and  Heitzmann  in  the  inflamed  cornea. 
They  are  always  found  around  foreign  bodies,  becoming  encysted  in  the 
tissues.  Friedlander  found  them  present  in  the  alveoli  of  the  lungs  in  cases 
of  chronic  pneumonia. 

Heubner  found  giant  cells  in  endarteritis,  Baumgarten  in  gummata. 
Buhl  and  Jacobson  in  granulating  wounds,  and  flnally  Johne  and  Pflug  in 
actinomycotic  foci.  The  histological  source  of  these  cells  in  tubercular  af- 
fections has  been  traced  to  epithelial  cells  by  Zielonko  and  Weigert;  to  endo- 
thelial cells  by  Kundrat,  Klebs,  Herrenkohl,  and  Zielonko;  to  connective 
tissue  or  endothelial  cells  by  Virchow,  Fleming,  and  Ziegler.     Schueppel 


HISTOLOGICAL    STEUCTUEE    OF    TUBEECLE. 


497 


and  Kindfleisch  belieye  that  they  invariably  originate  within  blood-vessels 
or  lymphatics,  where  these  authors  regard  them  as  the  first  step  toward  the 
development  of  tuberele-nodules.  Ziegier  claims  to  have  seen  giant  cells 
develop  from  white  blood-corpuscles.  Hering,  Aufrecht,  Woodward, 
Schueller,  and  Treves  are  of  the  opinion  that  what  appear  as  giant  cells 
in  tubercular  tissue  are  not  cells,  but  only  represent  spaces  which  correspond 
to  transverse  sections  of  lymphatic  channels,  the  protoplasm  representing 
the  coagulated  lymph  within  these  vessels,  and  what  appear  as  nuclei  being 
enlarged,  swollen  endothelial  cells.  Giant  cells  possess  amoeboid  movements, 
and  by  virtue  of  these  they  are  capable  of  taking  up  in  their  protoplasm  fine 
particles,  such  as  microbes,  pigment-material,  and  blood-corpuscles  which 
have  undergone  fragmentation.     The  giant  cells  in  tubercular  lesions  are 


Fig.  173.— Giant  Cell  from  Centre  of  Tubercle  of  Lung.  A,  granular  protoplasmic 
centre;  B,  peripheral  more-formed  part;  C,  crescent  of  nuclei;  D,  endothelium-like 
cells;    E,  two  vacuoles  within  the  giant  cell.     X  450.     {Hamilton.) 

hyperplastic,  epithelioid  cells,  and  consequently  are  derived  from  the  same 
histological  sources  as  these. 

Epithelioid  Cells. — Cells  intermediate  in  size  between  the  giant  cells 
and  the  leucocytes  are  found  in  every  tiibercle-nodule  in  which  the  cells  have 
not  been  destroyed  by  caseation.  These  cells  were  first  described  by  Eind- 
fleisch,  and  were  called  by  him  epithelioid  cells  from  their  structural  resem- 
blance to  epithelial  cells.     Klebs  calls  them  platycytes. 

They  are  about  two  or  three  times  larger  than  a  white  blood-corpuscle, 
and  in  shape  they  are  either  round  or  somewhat  elongated.  In  structure 
they  are  finely  granular,  and  contain  one  large  and  often  a  number  of  small 
nuclei.  They  form  the  bulk  of  all  recent  nodules,  are  scattered  between  the 
giant  cells,  and  are  often  arranged  in  layers  around  them.    The  histological 


498  PEINCIPLES    OF    SUEGEEY, 

source  of  these  cells  was  suioposed  to  be  the  leucocyte  by  Schueppel,  Ziegler, 
and  Treves;  the  endothelial  cells  of  the  lymph-spaces  by  Aufrecht,  Hering, 
and  Woodward;  the  endothelial  cells  of  the  blood-vessels  and  lymphatics 
or  connective-tissue  cells  by  Rindfleisch  and  nearly  all  of  the  modern  au- 
thors. The  epithelioid  cells  are  the  embryonal  cells,  the  product  of  prolifera- 
tion from  any  of  the  fixed  tissue-cells  in  a  tubercular  lesion,  and  they  remain 
as  such  until  they  are  destroyed  by  degenerative  changes  from  the  continued 
action  upon  them  of  the  bacillus  of  tuberculosis  or  its  toxins,  or  until,  on 
cessation  of  the  primary  cause,  they  are  transformed  into  tissue  of  greater 
durability. 

Reticuluin. — Schueppel  first  called  attention  to  the  reticulated  struct- 


Pig.  174. — Tuberculosis  of  Trochanteric  Bursa.    A,  A,  A,  A,  giant  ceUs;    B,  caseous 
contents  of  bursa;    C,  epithelioid  cells  and  leucocytes.    X  200. 

ure  of  tubercle  by  his  description  of  the  reticular  arrangement  within  tuber- 
cles of  lymphatic  glands. 

The  recticulum,  according  to  most  authors,  consists  of  the  preexisting 
connective  tissue  pushed  asunder  by  the  new  cells.  According  to  Wagner, 
Schueppel,  Brodowski,  Thaon,  and  Ziegler,  it  is  made  up  of  protoplasm. 
Buhl  taught  that  the  giant  and  epithelioid  cells  secrete  a  substance  at  their 
periphery  which,  on  becoming  firm,  is  formed  into  a  structure  resembling 
connective  tissue.  According  to  his  researches,  only  the  marginal  zone  is  sup- 
plied with  loose,  ready-formed,  connective  tissue  of  the  organ.  Wahlberg 
maintained  that  the  principal  reticulum  consists  of  protoplasm  which  is 
traversed  by  a  net-work  of  connective  tissue.  The  reticulum  is  always  more 
marked  in  the  periphery  of  the  tubercle-nodule,  where,  from  pressure,  it  is 
condensed  into  a  fibrous  capsule  (Fig.  176,  C). 


HISTOLOGICAL    STKUCTUEE    OF   TUBERCLE.  499 

Arrangement  of  the  Cells  in  a  Eecent  Tubercle-nodule. — A  fully-de- 
veloped typical  tubercle  is  called  a  Langlians  tubercle  because  it  was  iirst  ac- 
curately described  by  this  author.  The  earliest  evidence  of  the  formation 
of  a  tubercle-nodule,  as  witnessed  under  the  microscope,  is  the  appearance 
of  small  cells  which  resemble  ordinary  embryonal  cells,  which  are  the  prod- 
uct of  tissue-proliferation  from  a  mesoblastic  matrix,  usually  the  connective 
tissue,  and  its  embryological  and  histological  prototype,  the  endothelial  cells 
of  blood-vessels  and  lymphatics.  From  these  cells  the  epithelioid  and  giant 
cells  are,  later,  developed.  Some  of  the  central  cells,  by  appropriation  of  a 
superabundance  of  food  furnished  by  leucocytes  in  a  state  of  fragmentation, 
become  hyperplastic,  and  are  transformed  into  giant  cells;  these  occupy  the 
centre  of  the  nodule.     Around  these  cells  the  smaller  or  epithelioid  cells 


Fig.  175.— Section  from  IWucous  Membrane  of  Pharynx,  showing  Epithelioid  Cells  with 
a  few  Small  Giant  Cells.     X  350.     {Birch-Hirschfeld.) 

arrange  themselves,  and  between  them  and  in  the  priphery  of  the  nodule 
are  found  the  smallest  cells:  the  leucocytes. 

G-aule  and  Tizzoni  distinguish  three  zones  in  a  tubercle:  (1)  an  external, 
composed  of  small,  round  cells;  (2)  a  lesser,  epithelial,  or  middle  zone,  con- 
taining the  reticulum;  (3)  a  central  space  containing  a  giant  cell.  The 
structure  of  a  tubercle  is  not  always  typical,  and  hence  the  division  into 
zones  is  based  more  on  theoretical  grounds  than  actual  observation.  The 
giant  cell  is  not  an  essential  histological  element  of  tubercle,  but  an  acci- 
dental product.  In  some  tubercles  giant  cells  cannot  be  found,  while  in 
others  they  are  numerous.  Giant  cells  can  only  develop  from  epithelioid 
cells  if  the  local  conditions  are  favorable  for  hypernutrition;  that  is,  if  the 
leucocytes  in  a  condition  of  fragmentation  are  within  their  reach.    If  they 


500 


PEINCIPLES    OF    SUEGEKY. 


are  present  they  always  mark  the  location  of  the  starting-point  of  the  tnher- 
cular  infection,  as  only  the  older  epithelioid  cells  undergo  this  change.  The 
number  and  size  of  the  epithelioid  cells  are  also  subject  to  great  variation, 
and  are  modified  by  the  nutritive  conditions  within  and  in  the  immediate 
vicinity  of  the  nodule.  If  cell-proliferation  is  active  the  epithelioid  cells 
appear  densely  packed  in  the  reticulum,  nutrition  is  greatly  impaired,  and 
the  new  cells  undergo  degenerative  changes  before  they  attain  their  average 
size.     The  leucocytes  are  scattered  among  the  giant  and  epithelioid  cells. 


Fig.  176.— Fully-Developed  Reticular  Tubercle  of  Lung.  A,  A,  A,  giant  cells;  B, 
vacuole  in  one  of  these;  C,  peripheral  capsule  of  fibrous  tissue;  D,  reticulum  of  the 
tubercle;  E,  large  endothelium-like  cells  lying  on  the  reticulum  and  within  its  meshes; 
F,  smaller  "lymphoid"  cells  occupying  the  same  situation;  G,  peripheral  fibrous-look- 
ing border  of  the  giant  cells.     X  450.     ^Hamilton.) 

and,  as  they  reach  the  part  through  the  inflamed  wall  of  the  capillaries  in  the 
immediate  vicinity,  they  are  most  numerous  in  the  periphery  of  the  nodule 
and  along  the  course  of  the  affected  vessels. 


GEOWTH    OP   THE    TUBEEGLE-NODULES. 


The  typical  tubercle-nodule  is  microscopical  in  size.  The  growth  of 
the  SAvelling  depends  on  the  formation  of  new  tissue,  migration  of  leucocytes, 
and  confluence  of  nodules  into  larger  masses.    The  bacillus  of  tuberculosis, 


PATHOLOGICAL    VAKIETIES    OF    TUBERCLE,  501 

when  brought  in  contact  with  fixed  tissue-cells  susceptible  to  its  pathogenic 
action,  incites  tissue-proliferation,  which  always  takes  place  by  karyokinesis. 
Baumgarten's  investigations  leave  no  doubt  that  phatycytes  constitute  the 
entire  mass  of  the  forming  tubercle.  He  has  also  observed  karyokinetic  fig- 
ures in  tubercular  tissue  in  cells  derived  from  the  connective  tissue,  endo- 
thelia,  and  epithelia.  The  tubercle  bacilli  are  found  in  the  interior  of  giant 
and  epithelioid  cells  and  between  them. 

Each  tubercle-nodule  increases  in  size  by  the  growth  of  new  cells  from 
preexisting  tissue;  and,  as  the  primary  cause,  the  bacillus  of  tuberculosis, 
multiplies  in  the  tissues,  bacilli  are  conveyed  into  the  surrounding  tissues  by 
leucocytes  or  the  plasma-current,  and  new  centres  for  tubercle-formation 
are  established,  which,  later,  become  confluent,  forming  masses  of  consider- 
able size,  the  numerous  foci  of  caseation  corresponding  to  the  centres  of  so 
many  nodules.  The  growth  of  tubercle  is  favored  by  local  and  general  con- 
ditions which  diminish  tissue-resistance,  while  retardation  takes  place  in 
consequence  of  degenerative  changes  in  the  cells  of  which  it  is  composed, 
or,  if  the  cells  are  converted  into  tissue  of  a  higher  type,  from  disappearance 
or  suspension  of  activity  of  the  primary  cause. 

PATHOLOGICAL    YAEIETIES    OF    TUBERCLE. 

Several  varieties  of  tubercle  have  been  described,  according  to  the  his- 
tological structure  of  the  tubercle  or  the  structure  or  condition  of  the  cells 
of  which  it  is  composed. 

Reticulated  Tubercle. — -This  is  the  ordinary  form  of  tubercle  usually 
met  with,  and  the  most  important  anatomical  feature  is  the  presence  of  a 
well-defined  reticulum,  composed  of  preexisting  connective  tissue  and  a 
delicate  net-work  of  branching  giant  cells,  in  the  meshes  of  which  are  found 
the  epithelioid  cells  and  leucocytes. 

Fibrous  Tubercle. — In  contradistinction  to  the  reticulated  or  lymphoid 
tubercle,  a  few  years  ago  the  fibrous  tubercle  was  described,  distinguished 
by  its  pearl-like,  light-gray  appearance,  but  possessing  the  same  inherent 
tendency  to  caseation.  It  is  said  to  be  found  most  frequently  in  dense, 
fibrous  tissue,  and  quite  often  in  newly-formed  connective  tissue.  Histo- 
logically it  is  composed  of  nodules  of  dense  connective  tissue,  the  cells  of 
which  have  undergone  rapid  growth,  containing,  frequently,  more  than  one 
nucleus.  A  further  development  only  takes  place  in  the  interior  of  the 
nodule,  as  here  caseation  occurs,  the  caseous  focus  being  surrounded  by  a 
firm  capsule  of  connective  tissue.  The  description  of  fibrous  tubercle  by 
Langhans  differs  materially  from  the  above.  According  to  investigations  of 
this  author,  the  fibrous  tubercle  has  for  its  favorite  location  the  so-called 
parenchymatous  organs,  as  the  lungs,  liver,  spleen,  kidneys,  testicles,  epi- 
didymis, and  brain.    The  larger  nodules  are  composed  of  three  zones.    The 


502  PEINCIPLES    OF    SUEGEEY. 

central  zone  consists  of  a  few  connective-tissue  fibres,  free  oil-globules,  and 
cells  in  a  condition  of  fatty  infiltration.  The  middle  zone  is  composed  of  con- 
nective tissue.  As  the. cells  of  this  zone  are  not  numerous,  it  presents  the 
appearance  of  a  capsule;  in  reality,  however,  it  is  not  a  capsule  in  the  proper 
sense  of  the  word,  but  a  matrix  of  tissue-proliferation,  from  which  the  cen- 
tral part  of  the  tubercle  is  the  ofi:spring.  Both  Langhans  and  Schueppel, 
like  nearly  all  of  the  modern  pathologists,  regard  fibrous  tubercle  not  as  a 
distinct  special  anatomical  form,  bu.t  as  an  ordinary  tubercle  in  which  the 
epithelioid  cells  in  the  peripheral  zone  have  been  converted  into  connective 
tissue.  Fibrous  tubercle  differs  from  the  ordinary  cellular  variety  only  in 
so  far  that  it  contains. a  larger  amount  of  connective  tissue.  If  in  a  tubercle- 
nodule  at  the  time  the  young  cells  are  yet  vigorous  the  primary  microbic 
cause  ceases  to  act,  degenerative  changes  fail  to  take  place  and  the  embryonal 
cells  are  transformed  into  connective  tissue.  The  cicatricial  condition 
starves  out  remaining  embryonal  cells.  At  the  same  time  an  impermeable 
wall  of  connective  tissue  is  thrown  around  the  primary  depot  of  infection, 
which  effectually  guards  against  the  escape  of  active  bacilli  or  their  spores 
into  the  surrounding  tissues. 

Hyaline  Tubercle. — Chiari  described  another  variety  of  tubercle:  the 
hyaline  tubercle.  The  first  specimen  in  which  he  found  this  variety  was 
taken  from  the  liver  of  a  tubercular  child  4  years  of  age.  The  nodules  in 
the  brain,  lungs,  and  bronchial  glands  in  the  same  case  presented  the  ordi- 
nary structure  of  lymphoid  tubercle.  The  clear  hyaline  structure  of  those 
found  in  the  liver  gave  them  a  very  peculiar  appearance.  The  change  is 
believed  to  be  due  to  a  hyaline  degeneration  of  the  reticulum,  and  resembled 
most  closely  the  hyaline  degeneration  of  the  capillaries  of  the  brain.  Chiari 
conjectures  that  it  may  be  regarded  as  a  benign  change  opposed  to  casea- 
tion, which  tends  to  infection.  Hyaline  degeneration  of  any  pathological 
product  must  now  be  considered  as  one  of  the  earliest  phases  of  coagulation- 
necrosis,  and,  if  a  considerable  area  of  the  nodule  undergo  this  change  rap- 
idly and  simultaneously,  the  structures  will  present  a  hyaline  appearance; 
but,  if  the  hyaline  product  continue  to  be  acted  upon  by  the  same  causes, 
caseation  will  follow,  and  the  hyaline  tubercle  becomes  a  cheesy  tubercle. 

CASEATION. 

The  gray,  or  miliary,  tubercle  is  transformed  into  the  yellow,  crude,  or 
cheesy  tubercle  by  a  process  which  is  called  caseation,  or  tyrosis.  The  exact 
nature  of  this  process  remains  unknown.  The  cheesy  material  is  composed 
of  the  products  of  cell-necrosis.  Early  death  of  cells  is  the  most  character- 
istic pathological  feature  of  tubercle,  which  distinguishes  it  from  all  other 
forms  of  chronic  inflammation.  Two  causes  can  be  advanced  to  explain  this 
peculiar  and  almost  pathognomonic  form  of  degeneration,  which  occurs, 


CASEATION, 


503 


almost  without  exception,  in  every  tubercle  if  a  sufficient  length  of  time  has 
elapsed:  1.  Inadequate  blood-supply.  2.  Specific  action  of  the  bacillus  of 
tuberculosis  or  its  toxins.  Caseation  always  commences  in  the  centre  of  a 
nodule,  consequently  at  a  point  most  remote  from  the  vascular  supply,  and 
in  cells  which  have  been  exposed  longest  to  the  deleterious  effect  of  the  pri- 
mary microbic  cause.  Tubercle  is  a  non-vascular  product.  From  causes 
which,  as  yet,  are  not  known,  the  tubercular  product  is  not  supplied  with 
new  blood-vessels.  The  angioblasts  are  transformed  into  epithelioid  cells 
that  have  lost  their  power  of  vessel-formation.  Kodules  which  have  pri- 
marily an  intravascular  origin  are  rendered  avascular  by  closure  of  the  vessel 
from  intravascular  and  perivascular  cell-proliferation.    If  the  primary  start- 


Fig.  177. — Tuberculosis  of  Trochanteric  Bursa.     Recent  area  of  invasion,  sliowing  blood- 
vessels.   A,  A,  blood-vessels;    B,  B,  giant  cells;    C,  0,  epithelioid  cells.     X  500. 


ing-point  is  outside  of  the  vessels,  the  rapidly-accumulating  cells  exert  press- 
ure upon  the  su.rrounding  vessels,  and  thus  diminish  the  blood-supply  to 
the  part  affected.  The  new  cells  require  an  adequate  blood-supply  for 
their  further  development,  and  if  this  fail  to  take  place,  as  is  the  case  in 
every  tubercular  product,  they  necessarily  suffer  from  malnutrition,  and  un- 
dergo degenerative  changes  at  an  early  stage  of  their  existence.  A  deficient 
blood-supply,  in  the  absence  of  other  causes,  would  result  in  fatty  degenera- 
tion of  the  new  tissues;  but  caseation  is  something  different  from  ordinary 
fatty  degeneration,  and  the  bacillus  of  tuberculosis  or  its  toxins  must  be  re- 
garded as  its  immediate  and  essential  cause.  Caseation  is  preceded  by  coag- 
ulation-necrosis, which  is  one  of  the  results  of  the  specific  action  of  the 
bacillus  on  the  tissues.     The  coagulation-necrosis  commences  in  the  giant 


504  PEINCIPLES    OF    SUEGEEY. 

cells,  and  in  the  epithelioid  cells  in  the  centre  of  the  nodule,  and  caseation 
follows  as  soon  as  the  dead  cells  have  lost  their  histological  identity  and 
appear  imder  the  microscope  as  a  debris  in  which  no  distinct  cell-forms  can 
be  identified.  Caseation  is  attended  by  softening,  which  can  be  readily  rec- 
ognized in  tubercular  masses  the  size  of  a  hazel-nut  to  that  of  a  walnut,  com- 
posed of  numerous  confluent  nodules  with  as  many  caseating  foci. 

In  such  masses  the  small,  cheesy  cavities  become  confluent  and  form 
spaces  of  considerable  size.  Caseation  proceeds  from  the  centre  of  each- 
nodule  toward  the  periphery,  layer  after  layer  of  epitheloid  cells  being  de- 
stroyed and  changed  into  cheesy  material.  The  part  of  a  tubercle-nodule 
which  has  undergone  caseation  contains  few  or  no  bacilli,  and  yet  inocula- 


Fig.  178. — Caseated  Submaxillary  Gland.  A,  connective-tissue  capsule  of  gland; 
B,  small,  round  cells  of  gland,  indistinguishable  except  by  number  from  gland-lympbo- 
cytes  proper;    C,  area  of  caseation;    D,  giant  cells. 

tion  experiments  show  it  to  be  highly  infectious.  The  cheesy  material  does 
not  furnish  the  proper  nutrient  material  for  the  growth  and  development  of 
the  bacillus,  which  dies  from  starvation,  while  the  spores,  being  more  dur- 
able and  possessing  greater  power  of  resistance,  remain  in  an  active  condi- 
tion for  an  indefinite  period  of  time  in  the  dead  material,  and  it  is  due  to 
their  presence  that  infection  takes  place  from  cheesy  foci  and  that  successful 
inoculations  can  be  made  with  cheesy  material.  While  the  disease  has  be- 
come arrested  in  the  centre  of  a  nodule,  with  the  appearance  of  caseation, 
its  growth  in  a  peripheral  direction  pursues  the  same  relentless  course.  The 
bacilli  multiply  in  fresh  tubercular  tissue,  and  are  carried  beyond  the  pe- 
.ripheral  zone  into  the  surrounding  tissues,  where  new,  independent  foci  of 
infection  are  thus  established,  which,  in  the  course  of  time,  pass  through 


CALCIFICATION.  '  505 

the  same  series  of  joathological  changes  as  the  primary  nodules.  It  is  a  well- 
known  clinical  fact  that  acute  miliary  tuberculosis  is  not  a  primary  affection, 
as  in  all  such  cases  a  careful  post-mortem  examination  will  reveal  the  pres- 
ence of  a  cheesy  focus  in  a  lymphatic  gland,  the  lungs,  testicles,  a  joint,  or 
bone,  or  some  other  organ  from  which  the  infection  occurred.  Weber  found 
cheesy  foci  in  16  cases  of  tuberculosis  of  serous  membranes.  The  cheesy 
mass  may  lie  latent  so  long  as  it  is  solid,  but  as  soon  as  it  liquefies  the  spores 
which  it  contains  can  be  taken  up  by  the  blood-vessels  and  become  the  cause 
of  general  infection. 

CALCinCATIOiSr. 

One  of  IsTature's  means  in  preventing  the  local  extension  of  tubercle 
and  in  guarding  against  regional  and  general  infection  is  calcification  of  the 
tubercular  product.  This  can  only  occur  as  a  secondary  condition  in  tuber- 
cles that  have  undergone  caseation.  Calcification  implies  the  removal  of 
the  cheesy  material  and  the  substitution  for  it  of  inorganic,  calcareous  ma- 
terial. It  is  a  process  which  greatly  resembles  petrifaction.  Arrest  of  the 
tubercular  process  by  caseation  and  calcification  frequently  takes  place  in 
the  lungs,  and,  occasionally,  in  the  lymphatic  glands. 

32a 


CHAPTEE  XX. 

Clinical  Foems  of  Suegical  Tubeeculosis. 

It  is  but  a  few  years  since  it  was  thought  impossible  that  any  other 
organ  than  the  lungs  could  be  the  seat  of  tuberculosis.  The  different  forms 
of  surgical  tuberculosis  that  will  be  described  below  were  not  correctly  un- 
derstood until  quite  recently,  and  consequently  a  rational  surgical  treatment 
was  out  of  question.  Most  all  of  the  localized  tubercular  processes  were  in- 
cluded under  the  general  term  scrofula,  and  Avere  regarded  as  local  mani- 
festations of  a  general  dyscrasia,  and  treated  in  accordance  with  this  view 
of  their  pathology.  The  discovery  of  the  bacillus  of  tuberculosis  has  ren- 
dered the  word  scrofula  obsolete,  and  has  assigned  to  the  tubercular  proc- 
esses in  the  various  organs  and  tissues  of  the  body  their  correct  etiological 
and  pathological  significance,  and  paved  the  way  for  their  more  successful 
surgical  treatment.  There  is  hardly  a  tissue  in  the  body  which  may  not  be- 
come the  primary  seat  of  tubercular  infection,  or  which  escapes  when  diffuse 
dissemination  occurs  through  the  medium  of  the  general  circulation.  The 
frequency  of  tubercular  affections  is  something  appalling.  At  least  1  person 
out  of  every  7  dies  of  some  form  of  tuberculosis.  Most  of  the  large  hospitals 
contain  from  25  to  50  per  cent,  of  patients  afflicted  with  this  disease.  The 
ravages  of  the  disease  are  to  be  seen  everywhere,  in  the  shape  of  disfiguring 
scars  of  the  neck,  deformed  limbs,  and  bent  spines.  Health  resorts,  fre- 
quented for  years  by  tubercular  patients,  have  become  infected  to  such  an 
estent  that  there  is  great  danger  of  the  whole  population  becoming  exter- 
minated by  this  disease.  The  sources  of  infection  in  such  places  have  be- 
come so  numerous  that  it  is  unsafe  to  breathe  the  air,  to  drink  the  water, 
or  to  eat  the  food  prepared  in  houses  which  for  years  have  been  hot-beds 
for  the  bacillus  of  tuberculosis,  and  by  persons  carrying  the  microbe  upon 
every  square  inch  of  their  surface.  That  whole  communities  and  nations, 
where  this  disease  has  been  prevalent  for  centuries,  have  not  been  completely 
depopulated  long  ago  is  owing  to  the  fact  that  many  persons  possess,  from 
the  time  of  their  birth,  a  degree  of  resistance  to  infection  that  even  direct 
infection  by  inoculation  would  prove  harmless.  The  bacillus  is  not  the  sole, 
but  the  essential,  cause  of  tuberculosis. 

HEEEDITAEY    AND    ACQUIEED    PEEDISPOSITION. 

Almost  every  author  recognizes,  as  an  important  element  in  the  etiology 
of  tuberculosis,  the  existence  of  an  hereditary  or  acquired  predisposition. 
Little  is  known  in  reference  to  the  real  nature  of  such  a  predisposition.  A 
weakness  of  the  lymphatic  vessels  in  scrofulosis  was  recognized  by  Sylvius 

(506) 


HEEEDITAEY    xiND   ACQUIKED    PEEDISPOSITION.  507 

as  early  as  1695,  by  Portal  in  1690,  and  still  later  by  Bell,  Percival  Pott, 
Hufeland,  and  Bronssais.  Fox  is  of  the  opinion  that  a  disposition  to  tuber- 
culosis is  created  by  certain  anatomical  or  physiological  defects  in  the  lym- 
phatic system.  The  cause  of  scrofula  was  ascribed  by  Virchow  to  a  weakness 
or  imperfection  in  the  arrangement  of  the  lymphatic  system;  by  Hueter  to  a 
dilatation  of  lymph-spaces;  and  by  Billroth  to  a  constitutional  anomaly. 
Mordhorst  regards  a  sluggish  circulation,  the  consequence  of  superficial,  im- 
perfect respiration,  by  causing  capillary  stasis  and  favoring  inflammatory 
exudation,  a  potent  factor  in  producing  that  peculiar  vulnerability  of  the 
tissues  in  scrofulous  subjects.  Eokitansky  placed  great  stress  on  the  impor- 
tance of  an  imperfect  circulatory  and  respiratory  apparatus  as  a  predispos- 
ing cause  of  tuberculosis.  In  1871  Friedlander  suggested  that  in  cases  of 
tuberculosis  there  might  be  present,  and  active,  a  fusion  of  the  scrofulous 
and  tubercular  diathesis:  a  view  which  was  indorsed  by  Charcot  in  1877. 
Aufrecht  claims  that  the  disposition  to  the  origin  of  tubercle  may  be  found 
in  the  lymphatic  vessels.  Eiedel  defines  the  hereditary  predisposition  to 
tuberculosis  as  consisting  in  a  peculiar  defect  in  the  anatomical  arrangement 
of  the  tissues,  especially  of  the  lymphatic  glands,  which  furnish  a  favorable 
soil  for  infection.  Schliller  believes  that  the  noxse  of  tuberculosis  excite  a 
slow  form  of  inflammation,  with  a  tendency  to  speedy  retrograde  metamor- 
phosis of  the  new  material.  Quincke  recognized  a  close  relationship  between 
scrofula  and  tuberculosis,  when  he  says:  "Scrofulous  persons  are  especially 
predisposed  to  tuberculosis;  tuberculosis  hardly  ever  occurs  except  in  scrof- 
ulous persons."  Ziegler  was  aware  that  pulmonary  phthisis  is  the  most  fre- 
quent cause  of  death  in  scrofulous  patients. 

Wliittaker,  in  comparing  the  etiology  of  tuberculosis  with  syphilis, 
makes  use  of  the  following  very  positive  language :  "There  is  no  such  a  thing 
as  a  predisposition  to  either  disease.  Either  a  man  has  syphilis  or  he  has  it 
not.  One  man  is  not  more  predisposed  to  either  disease  than  another.  Syph- 
ilis affects  one  individual  more  than  another  because  its  virus  finds  a  better 
lodgment  upon  mucous  membrane.  Tuberculosis  finds,  also,  fortuitously, 
a  better  nidus  in  one  case  than  another.  The  virus  of  tuberculosis  is  lodged, 
in  one  case,  and  not  coughed  up,  just  as  in  syphilis  the  virus  is  secreted  and 
not  washed  of!."  And  again:  "From  any  chancre,  plaque,  gumma,  or  other 
deposit  of  syphilis,  reabsorption  may  take  place  at  any  time,  and  reinfection 
with  syphilis;  or,  better,  reappearance  of  external  signs.  So,  from  any  case- 
ous nodule,  wherein  the  tuberculous  virus  is  locked  up  in  temporary  inno- 
cence, absorption  may  take  place  under  favoring  circumstances,  and  a  new 
outbreak  of  tuberculous  symptoms  appear,  the  quantity  of  virus  thus  set  free 
determining,  to  a  great  extent,  perhaps,  the  virulence  of  the  symptoms. 
While  the  virus  is  thus  locked  up,  the  disease  is  latent;  when  set  free,  it  is 
manifest."     Wynne  Foot  says:    "Tubercles  are  small-celled  overgrowths  of 


508  PRINCIPLES    OF    SURGERY. 

lymphatic  tissue  that  have  preserved  such  uniformity  of  size^,  color,  and  shape 
as  to  have  long  suggested  the  probability  of  their  lymphatic  origin/'  Wilson 
Fox  regarded  tubercle  as  an  overgrowth  or  hyperplasia  of  lymphatic  tissue 
resulting  from  irritation  of  the  lymphatic  elements.- 

Savory,  in  speaking  of  the  relation  of  scrofula  to  tubercle,  remarks: 
"It  appears  to  me  that  there  is  nothing  sufficient  to  warrant  the  pathological 
distinction  which  it  is  now  the  fashion  to  make  between  scrofula  and  tuber- 
cle.^'  And  further:  "Tubercle  may  be  said  to  be  the  essential  element  of 
scrofula.^'  According  to  Eokitansky,  the  most  frequent  seat  of  tubercle  in 
children  is  in  the  lymphatic  glands.  Virchow  maintained  that  scrofula  con- 
stitutes the  basis  of  tubercle,  and  that  in  man  tuberculosis  depends  in  gen- 
eral on  scrofula.  He  asserts,  further:  "On  account  of  the  histological  iden- 
tity of  the  scrofulous  and  tubercular  new  growths,  it  is  often  impossible,  in 
a  given  tubercular  lesion,  to  determine  how  much  is  inflammatory  and  how 
much  is  tubercular."  From  the  above  quotations  it  becomes  apparent  that 
nearly  all  of  the  older  authors  recognized,  if  not  the  identity,  at  least  a  close 
relationship  between  scrofula  and  tuberculosis.  The  identity  of  scrofula  and 
tuberculosis  was  established,  not  upon  anatomical  or  pathological  researches, 
but  was  definitely  settled  by  the  discovery  of  the  same  cause  in  the  local 
lesions  of  both.  Clinical  and  experimental  proof  is  accumulating  rapidly, 
establishing  the  fact  that  heredity  in  the  causation  of  tuberculosis  often 
means  direct  transmission  of  tubercle  bacilli  from  parents  to  child.  Birch- 
Hirschfeld  and  Schmore  have  reported  the  case  of  a  young  woman  who, 
early  in  her  first  pregnancy,  presented  signs  of  pulmonary  phthisis,  to  which 
she  succumbed  in  the  seventh  month.  Immediately  after  the  death  of  the 
mother  the  foetus  was  removed  by  Cgesarian  section.  Post-mortem  revealed 
tuberculosis  not  only  in  the  lungs,  but  also  in  other  organs  of  the  mother. 
Although  the  foetus  had  been  alive  shortly  before  the  death  of  the  mother, 
it  was  dead  when  removed.  Careful  examination  of  the  foetus  showed  no 
macroscopical  tubercular  lesions.  The  surface  of  the  abdomen  was  washed 
with  a  solution  of  bichloride  of  mercury  and  the  cavity  opened  with  steril- 
ized knives.  Small  fragments  of  the  internal  organs  were  implanted  into  the 
abdominal  cavities  of  two  guinea-pigs  and  a  rabbit.  One  of  the  guinea-pigs 
died  in  fourteen  days.  The  other  was  killed  at  the  end  of  six  weeks,  and 
many  tubercles  were  found  in  the  peritoneal  cavity.  The  rabbit  lived  for 
three  months.  On  its  death  many  tubercles  were  found  in  the  liver  and  lung. 
Tubercle  bacilli  were  found  in  the  umbilicus  and  in  the  blood  of  the  um- 
bilical vein  of  the  foetus.  The  demonstration  of  any  definite  anatomical 
defect,  hereditary  or  acquired,  which  acts  as  a  predisposing  cause  to  tuber- 
cular infection,  has,  so  far,  not  succeeded.  Only  a  few  years  ago  Formad 
made  some  interesting  studies  concerning  the  histological  structures  of  tis- 
sues that  are  known  to  be  prone  to  tubercular  infection,  and  he  believed  that 


TUBEECULAR   ABSCESS.  509 

the  changes  constantly  found  were  such  that  favored  the  arrest  of  migrating 
cells.  It  is  more  probable  that  the  hereditary  or  acquired  predisposition  to 
tuberculosis,  which  must  now  be  recognized  as  an  important  element  in  the 
causation  of  the  disease,  must  be  regared  rather  as  a  diminution  of  the  power 
of  resistance  inherent  in  the  tissues  to  the  action  of  the  specific  microbic 
cause  than  any  characteristic  anatomical  cell-defects.  From  a  clinical  stand- 
point, it  is  important  to  remember  that  in  the  causation  of  tuberculosis  we 
must  recognize  a  combination  of  etiological  factors,  viz.:  (1)  local  or  general 
conditions,  resulting  from  hereditary  or  acquired  causes,  which  diminish 
the  resisting  capacity  of  the  tissues  to  the  action  of  the  bacillus  of  tuber- 
culosis, which  must  be  regarded  as  the  predisposing  cause;  and  (3)  the  pres- 
ence in  the  tissues  of  the  essential  cause  of  the  disease, — the  bacillus  of  tu- 
berculosis. 

The  predisposing  cause  can  under  no  circumstances  result  in  tuberculo- 
sis without  action  of  the  essential  cause,  and  the  bacillus  of  tuberculosis  is 
most  certain  to  produce  its  specific  pathogenic  effect  in  tissues  debilitated 
by  hereditary  or  acquired  causes.  The  different  avenues  through  which  in- 
fection takes  place  will  be  referred  to  in  the  further  discussion  of  the  sub- 
ject which  heads  this  chapter. 

TUBEECULAE    ABSCESS. 

Pathological  Anatomy. — The  effect  of  the  bacillus  of  tuberculosis  on 
the  tissue  is  to  produce  a  chronic  inflammation,  which  invariably  results  in 
the  production  of  granulation-tissue.  The  embryonal  cells  furnish,  as  it 
were,  a  wall  of  protection  for  the  surrounding  healthy  tissue.  The  charac- 
teristic pathological  feature  of  every  tubercular  product  consists  in  the  tend- 
ency of  the  cells  of  which  it  is  composed  to  undergo  early  degenerative 
changes,  which  are  caused  by  local  ansemia  and  the  specific  chemical  action 
of  the  toxins  of  the  tubercle  bacilli,  and  consist  in  coagulation-necrosis, 
caseation,  and  liquefaction  of  the  cheesy  material  into  an  emulsion,  which 
has  always  been  regarded  as  pus  until  recent  investigations  have  shown  that 
it  is  simply  the  product  of  retrograde  tissue-metamorphosis,  and  not  true  pus. 
I  believe  that  it  can  now  be  considered  as  a  settled  fact  that  the  bacillus  of 
tuberculosis  is  not  a  pyogenic  microbe,  and  that,  in  the  absence  of  other 
microbes,  it  produces  a  specific  form  of  chronic  inflammation,  which  in- 
variably terminates  in  the  formation  of  granulation-tissue;  and  that,  when 
true  suppuration  takes  place  in  the  tubercular  product,  it  occurs  in  conse- 
quence of  secondary  infection  with  jDUS-microbes.  The  so-called  tubercular, 
or  cold,  abscess  contains  a  fluid  which  macroscopically  resembles  pus,  but 
which,  when  examined  under  the  microscope,  shows  none  of  its  histological 
elements.  If  the  bacillus  of  tuberculosis  meet  with  sufiicient  resistance  on 
the  part  of  the  surrounding  tissues,  it  finally  exhausts  the  nutrient  material 


510  PEIJSrCIPLES    OF    SUEGERY. 

in  the  granulations  and  dies,  or  remains  in  a  latent  condition;  the  granula- 
tion-material is  converted  into  cicatricial  tissue  and  the  local  lesion  is  cured. 
The  cases  in  which  the  tubercular  product  is  removed  by  cicatrization  ter- 
minate most  frequently  in  spontaneous  cure.  If,  on  the  other  hand,  bacilli 
in  sufficient  number  are  present  to  destroy  the  granulation-cells,  coagulation- 
necrosis,  caseation,  and  liquefaction  of  the  infected  tissue  take  place;  a  spon- 
taneous cure  is  still  possible  if  a  part  of  the  fluid  portion  is  absorbed  and  the 
solid  debris  becomes  encapsulated.  The  same  favorable  termination  is  ex- 
pedited under  similar  circumstances  if  the  primary  lesion  has  healed  and 
the  inflammatory  product  is  removed  by  operative  interference  under  the 
strictest  antiseptic  precautions,  or  if,  at  the  same  time,  the  primary  focus 
can  be  completely  removed  by  extending  the  operation  to  the  primary  lesion. 
Secondary  infection  of  a  tubercular  product  with  pus-microbes  without  a 
direct  infection-atrium  is  possible,  and  if  the  primary  lesion  is  located  in  an 
unimportant  organ,  and  in  such  a  place  where  the  inflammatory  product 
can  be  early  reached  or  can  ^be  discharged  spontaneoush',  a  cure  is  often 
effected,  as  the  suppurative  inflammation  may  destroy  all  of  the  tissues  in- 
habited by  the  bacillus,  and  the  whole  nidus,  with  the  microbes  it  contains, 
is  eliminated  permanently  from  the  body.  Such  a  course  is  not  infrequently 
observed  in  cases  of  tuberculosis  of  the  lymphatic  glands  of  the  neck.  If, 
however,  the  tubercular  process  affect  important  organs  or  parts  deeply 
located  with  extensive  infection  of  tissue,  and  secondary  infection  with 
pus-microbes  take  place,  then  the  patient  incurs  the  danger  of  septic  infec- 
tion and  local  and  general  dissemination  of  the  tubercular  process  from  the 
breaking  down  of  the  protective  wall  of  granulation-tissue.  That  the  bacilli 
do  not  grow  in  a  tubercular  abscess  has  been  deflnitely  settled  by  Schleg- 
tendal.  He  examined  520  specimens  of  fluid  from  tubercular  abscesses,  and 
found  bacilli  present  in  only  75  per  cent.  Garre  has  also  made  an  extended 
series  of  observations  to  ascertain  the  presence  of  the  bacillus  in  cold  ab- 
scesses. According  to  this  author,  many  tubercular  ulcerations  and  abscesses 
are  the  result  of  a  mixed  infection,  as  has  been  claimed  by  Hoffa  for  some 
cases  of  empyema  complicating  pulmonary  or  pleural  tuberculosis.  In  cold 
abscesses,  and  in  the  liquefied  cheesy  material  of  tubercular  cavities  in  bone, 
no  pus-microbes  could  be  found;  not  even  in  cases  that  pursued  a  raj^id 
course.  Cultivations  of  such  material  remained  sterile,  while  inoculations 
produced  typical  tuberculosis.  Such  specimens,  examined  under  the  micro- 
scope, showed  none  of  the  morphological  elements  of  pus,  but  were  seen  to 
consist  of  an  emulsion  composed  of  fat-globules  and  detritus  of  broken-down 
tissue  suspended  in  serum.  Garre  believes  it  is  possible  that,  in  many  cases 
of  suppuration  following  in  the  course  of  a  tubercular  process,  pus  is  the 
result  of  a  mixed  infection,  and  that  the  pus-microbes  disappear  before  the 
examination  is  made. 


TUBEKCULAE   ABSCESS.  511 

Tavel  lias  examined  the  inflammatory  product  of  40  cases  in  which  a 
positive  or  at  least  probable  diagnosis  of  tuberculosis  was  made,  before  op- 
eration, for  evidences  of  mixed  infection,  by  means  of  microscopical  exam- 
ination of  stained  preparations  under  the  microscope,  cultivation  and  inocu- 
lative experiments.  In  30  he  found  the  tubercle  bacillus  exclusively,  in  5 
tubercle  bacilli  and  ^Dus-microbes;  the  latter,  however,  had  no  hematogenic 
source,  as  their  entrance  into  the  tubercular  focus  through  a  communication 
between  it  and  the  internal  or  external  surface  of  the  body  could  be  traced. 
In  the  last  5  cases  he  found  no  tubercle  bacilli,  but  a  mono-infection  with 
pus-microbes  which  had  produced  a  lesion  resembling  tuberculosis.  He  be- 
lieves, with  Garre,  that  tubercular  abscesses  are  caused  exclusively  by  tuber- 
cle bacilli,  but  he  assigns  to  these  pyogenic  properties.  He  maintains  that 
the  chemical  products  of  the  tubercle  bacillus  transforms  leucocytes  and 
embryonal  cells  from  the  fixed  tissue-cells  into  pus-corpuscles,  which,  how- 
ever, show  an  earlier  tendency  to  fatty  degeneration  and  granular  degenera- 
tion than  pus-corpuscles  in  the  pus  of  acute  abscesses. 

Prudden  and  Hodenpjd  killed  tubercle  bacilli  by  prolonged  boiling, 
and  still  foimd  them  markedly  chemotactic.  When  introduced  in  consider- 
able number  into  the  subcutaneous  tissue,  or  into  the  pleural  or  abdominal 
cavities,  they  are  distinctly  pyogenic,  causing  aseptic  localized  suppuration. 
Under  these  conditions  they  are  capable,  moreover,  of  stimulating  the  tis- 
sues about  the  suppurative  foci  to  the  development  of  a  new  tissue  closely 
resembling  the  diffuse  tubercle  tissue  induced  by  the  living  germs,  but  this 
tissue  manifests  no  tendency  to  caseation. 

The  walls  of  the  tubercular  cavity  contain  the  typical  structure  of  the 
tubercular  lesion  and  the  primary  and  essential  cause  of  the  inflammation: 
the  bacillus  tuberculosis.  The  infection  follows  the  migration  of  the  ab- 
scess in  whatever  direction  that  may  take  place.  If  an  additional  infection 
from  without  take  place,  following  either  a  spontaneous  discharge  or  after 
incision,  the  superflcial  granulations  are  destroyed  by  the  suppurative  process 
which  is  initiated,  exposing  the  patient  to  the  additional  risks  of  septic  in- 
fection and  a  more  rapid  local  and  general  dissemination  of  the  tubercular 
process. 

Symptoms  and  Diagnosis. — The  tubercular  abscess  is  called  a  cold  ab- 
scess because  it  lacks  the  characteristic  clinical  phenomena  which  attend 
the  development  of  an  acute  or  hot  abscess.  There  is  but  little,  if  any,  rise 
of  the  local  temperature,  and,  unless  the  abscess  has  reached  the  skin,  the 
surface  looks  rather  preternaturally  pale  than  red,  and  the  abscess  itself  is 
always  painless  and  not  tender  on  pressure.  The  pain,  if  present,  is  referred 
to  the  primary  seat  of  the  tubercular  inflammation.  Fluctuation  is  usually 
well  marked,  as  the  tissues  around  the  abscess  are  not  much  infiltrated.  The 
most  important  clinical  feature  of  a  cold  abscess  is  its  tendency  to  wander 


513  PRINCIPLES    OF    SUEGEEY. 

from  the  place  wliere  it  originated  to  distant  localities  by  gravitation;  hence 
title  name  given  to  it  by  German  writers:  Senkungsabscess.  Thus,  in  tuber- 
cular spondylitis  the  abscess  may  appear  in  the  lumbar  region,  and  is  then 
called  lumbar  abscess;  it  may  follow  the  iliac  muscle  and  appear  in  one  of 
the  iliac  regions,  and  is  then  called  iliac  abscess;  or,  finally,  it  may  follow  the 
psoas  muscle  and  appear  above  or  below  Poupart's  ligament,  when  it  con- 
stitutes a  psoas  abscess. 

In  tuberculosis  of  the  hip-joint  the  abscess  appears  posteriorly  under- 
neath the  gluteal  muscles,  if  perforation  of  the  capsule  in  this  direction  take 
place;  or  it  appears  anteriorly  a  considerable  distance  below  the  hip-joint,  if 
perforation  of  the  capsule  take  place  in  an  opposite  direction.  As  the  con- 
tents of  the  abscess  carry  the  original  cause  of  the  disease,  infection  of  the 
tissues  takes  place  along  the  whole  course  of  the  abscess,  which  is  always 
lined  with  infected  granulation-tissue.  Although  the  primary  cause  of  a 
tubercular  abscess  is  most  frequently  a  tuberculosis  of  a  joint  or  bone,  it  can 


'<.f>r.ik 


Fig.  179. — M"  iiil'i'.'iiii   Joining  Tubercular  Abscess.     {Landerer.) 

also  develop  in  the  course  of  any  localized  form  of  tuberculosis,  and  it  is 
quite  frequently  met  in  the  course  of  tuberculosis  of  the  lymphatic  glands. 
The  diagnosis  must  be  made  with  special  reference  to  the  nature  and  loca- 
tion of  the  primary  lesion.  In  tuberculosis  of  the  spine  the  fixed  pain  in  the 
region  of  the  afl:ected  vertebrae,  radiating  from  here  in  the  direction  of  the 
nerves  on  each  side,  is  an  important  symptom,  and  this  symptom  is  always 
aggravated  by  flexion  and  ameliorated  by  extension  of  the  spine.  In  coxitis 
the  23ain  in  the  beginning  of  the  disease  is  usually  referred  to  the  inner  aspect 
of  the  knee-joint,  but  is  always  increased  by  motion  in  the  hi]D-joint.  In 
cold  abscess,  caused  by  glandular  tuberculosis,  the  clinical  history  will  point 
to  a  chronic  inflammation  of  the  glands  which  preceded  the  formation  of 
the  abscess.  As  soon  as  the  abscess  reaches  the  skin  that  structure  becomes 
inflamed,  livid,  and  more  and  more  attenuated  by  pressure  and  inflammation, 
until  spontaneous  perforation  takes  place  at  a  point  subjected  to  greatest 
pressure.  If  a  tubercular  product  become  the  seat  of  a  secondary  infection 
with  pus-microbes,  the  subsequent  symptoms,  local  and  general,  are  those  of 


TUBERCULAK    ABSCESS.  513 

suppurative  inflammation.  Tlie  temperature,  wliicli  was  normal,  or  nearly 
so,  increases  and  presents  the  daily  curves  indicative  of  suppuration,  while 
the  abscess,  which  has  been  painless  heretofore,  becomes  painful  and  tender 
on  pressure;  in  fact,  a  chronic  inflammation  has  been  supplanted  by  an  acute 
one,  with  a  corresponding  change  of  the  clinical  picture.  If  any  doubt  re- 
main as  to  the  character  of  the  swelling  and  the  nature  of  its  contents,  this 
can  be  dispelled  at  once  by  resorting  to  an  exploratory  puncture.  In  cold 
abscess  the  fluid  removed  presents  the  appearance  of  serum  in  which  minute 
particles  of  broken-down  tissues  are  suspended,  while  in  an  abscess  caused 
by  a  mixed  infection  it  presents  the  macroscopical  and  microscopical  appear- 
ance of  pus. 

Prognosis. — The  danger  attending  tubercular  abscess  must  be  estimated 
exclusively  by  the  extent  and  location  of  the  primary  disease  and  the  pres- 
ence or  absence  of  tuberculosis  in  other  organs.  If  the  general  health  re- 
main unimpaired,  even  an  extensive  local  tubercular  disease  ma}^  be  amen- 
able to  a  spontaneous  cure  or  successful  surgical  treatment.  On  the  other 
hand,  a  tubercular  abscess  developing  in  the  course  of  an  insigniflcant  and 
unimportant  local  lesion  occurring  in  an  aneemic  person,  the  subject  of  in- 
cipient multiple  foci  in  different  organs,  must  be  regarded  as  a  formidable 
condition,  with  little  or  no  prospects  of  a  favorable  termination.  /  liave 
learned  to  regard  pronounced  wvcemia  as  an  unfavorable  symptom  in  the  dif- 
ferent forms  of  surgical  tuberculosis,  as  it  is  often  an  expression  that  general 
infection  has  occurred.  Another  important  matter  to  be  taken  into  consid- 
eration, in  making  a  prognosis  in  cases  where  general  infection  can  be  ex- 
cluded, is  the  possibility  of  eradicating  the  primary  lesion  b}^  operative  in- 
terference. Where  this  can  be  done,  the  chances  of  successful  treatment  of 
the  local  disease  are  much  better;  at  the  same  time,  the  removal  of  all  the 
infected  tissues  is  the  best  guarantee  against  general  infection.  Other  things 
being  equal,  the  prognosis  is  better  in  patients  without  an  hereditary  history 
of  tuberculosis,  and  in  young  persons  than  those  advanced  in  years. 

Treatment. — The  surgical  treatment  of  large  tubercular  abscesses  is 
always  fraught  with  danger  from  the  fact  that,  even  if  conducted  under 
strict  antiseptic  jorecautions,  it  is  not  always  possible  to  prevent  infection 
with  pus-microbes.  Large  tubercular  abscesses  were  a  "nole  me  tangere"  to 
the  older  surgeons,  as  it  was  well  known  evacuation  by  incision  would  be  fol- 
lowed within  a  few  days  by  hectic  fever,  profuse  sweating,  diarrhoea,  and 
other  symptoms  of  septic  infection.  The  early  advocates  of  the  antiseptic 
treatment  hoped  that  the  time  had  come  when  the  surgeon  had  it  in  his 
power  to  prevent  septic  infection  during  the  operation  by  resorting  to  the 
necessary  antiseptic  precautions,  and  to  maintain  an  aseptic  condition 
throughout  the  after-treatment  under  an  efficient  antiseptic  hygroscopic 
occlusive  dressing.     If  we  remember  that  in  cases  where  the  abscess  orig- 


514  PEINCIPLES    OF    SUEGEEY. 

inated  from  a  primary  lesion  inaccessible  to  direct  treatment  it  may  require 
months  for  the  healing  process  to  be  completed,  it  is  not  surprising  that  even 
the  strictest  aseptic  precautions  in  the  hands  of  the  ablest  surgeons  have 
often  failed  in  protecting  the  abscess-cavity  against  septic  infection  for  such 
a  long  time. 

In  a  number  of  tubercular  abscesses  originating  from  a  tubercular  focus 
in  the  vertebrse,  in  the  hip-  and  knee-  joints,  I  have  succeeded  in  preventing 
infection,  and  the  patients  were  cured  after  several  months  of  the  most 
careful  and  watchful  treatment;  but  in  a  greater  number  of  cases  infection 
occurred  at  the  time  of  operation,  or  weeks  or  months  later  during  change 
of  the  dressing,  or  in  consequence  of  a  slipping  of  the  dressing.  In  abscesses 
in  the  gluteal  or  inguinal  regions,  especially  in  children  treated  by  incision 
and  drainage,  it  is  almost  next  to  impossible  to  maintain  an  aseptic  condi- 
tion for  weeks  and  months,  and  the  most  careful  and  laborious  efforts  in 
this  direction  will  often  result  in  failure. 

(a)  Evacuation  by  Tapping  followed  by  Antiseptic  Irrigation  and 
Subcutaneous  lodoformization.  —  The  frequency  with  which  failures  have 
occurred  after  incision  and  drainage,  in  the  hands  of  the  most  enthusiastic 
followers  of  the  antiseptic  treatment,  has  again  roused  the  fear  of  surgeons 
in  attacking  large  tubercular  abscesses  by  incision  and  drainage,  and  the  sub- 
cutaneous evacuation  with  subsequent  disinfection  of  the  abscess-cavity  has 
again  come  into  favor.  That  iodoform  exerts  an  inhibitory  effect  on  the 
growth  of  the  bacillus  of  tuberculosis  is  now  generally  accepted.  Its  use 
in  the  treatment  of  tubercular  affections  is  almost  universal.  It  has  been 
extensively  used  for  injection  into  tubercular  abscess,  after  evacuation  by 
tapping,  since  Bruns  advocated  this  treatment  in  1887.  It  was  first  used  dis- 
solved in  ether  in  the  proportion  of  1  part  to  20.  The  ethereal  solution  has 
the  advantage  of  bringing  the  drug  in  contact  with  every  part  of  the  in- 
terior of  the  cavity  by  the  distension  which  takes  place  from  the  expansion 
of  the  ether  when  exposed  to  the  body-temperature,  but  the  injection  is 
usually  followed  by  considerable  pain.  Bruns  used  a  suspension  of  iodoforih 
in  glycerin  and  alcohol.  Eeeently  the  following  formula  was  suggested  by 
Krause: — 

lodoformi    subt.    pulveris 50.0 

Mucil.    gummi   arab 23.0 

Glycerin!    83.0 

Aquas   destillatae q.  s.  ad  500.0 

(Ten-per-cent.  iodoform  mixture.) 

A  safer  and  equally  efficient  preparation  is  a  simple  lO-per-cent.  mixt- 
ure of  iodoform  in  glycerin,  which  has  been  used  for  a  number  of  years  with 
such  marked  success  in  the  surgical  clinic  of  Eush  Medical  College,  Chicago. 
The  emulsion  is  sterilized  by  boiling. 

The  evacuation  of  the  abscess  is  to  be  done  with  an  ordinarv  trocar 


TUBEECULAR   ABSCESS.  515 

under  strict  aseptic  precautions.  The  surface  of  the  abscess  is  thoroughly 
disinfected  in  the  usual  manner,  and  the  instrument  rendered  aseptic  by 
boiling  in  soda  solution.  The  trocar  is  inserted  in  such  a  manner  that  a  track, 
at  least  an  inch  in  length,  is  made  underneath  the  skin  before  the  instrument 
is  plunged  into  the  abscess-cavity,  in  order  to  make  the  wound,  after  the  re- 
moval of  the  instrument,  as  nearly  as  possible  subcutaneous.  As  tubercular 
abscesses  usually  contain  shreds  of  dead  connective  tissue,  fragments  of  fibrin, 
and  masses  of  broken-down  granulation-tissue,  the  evacuation  is  often  at- 
tended by  a  considerable  difficulty,  as  these  substances  block  the  opening  of 
the  instrument  and  thus  prevent  evacuation.  The  simplest  procedure  to 
overcome  these  difficulties  is  to  introduce  through  the  cannula  a  small  hook 
made  by  bending  an  aseptic  wire,  and  to  extract  with  it  any  substance  which 
interferes  with  the  escape  of  the  fluid  contents.  Gentle,  uniform  pressure 
is  of  great  value  in  expediting  the  escape  of  the  contents  and  preventing  the 
entrance  of  air.  lodoformization  of  the  abscess-cavity  is  not  to  be  done  until 
complete  evacuation  of  solid  detached  particles  has  been  effected  by  means 
of  irrigation  with  a  3-per-cent.  solution  of  boric  acid.  This  can  be  readily 
done  with  the  injection-syringe  here  illustrated.  A  sufficient  quantity  of 
fluid  is  allowed  to  flow  into  the  caVity  until  this  is  distended  as  much  as 
before  the  evacuation  of  the  fluid,  when,  by  gentle  pressure,  it  is  forced  out 
through  the  cannula.  By  filling  and  emptying  the  cavity  alternately  in  this 
manner  a  requisite  number  of  times,  complete  evacuation  of  the  fluid  and 
loose  solid  contents  is  effected,  and  the  cavity  is  now  ready  for  lodoformiza- 
tion. The  iodoform  injection  is  made  with  the  same  syringe.  Whatever 
formula  for  the  solution  is  selected,  not  more  than  half  a  drachm  of  the 
iodoform  should  be  injected  at  the  first  time,  and  in  children  even  less.  If 
this  dose  does  not  produce  any  unpleasant  symptoms,  it  may  be  increased 
the  next  time  the  operation  is  repeated.  There  seems  to  be  very  slight  dan- 
ger of  iodoform  intoxication,  not  even  a  symptom  of  this  being  observed  in 
109  cases  thus  treated  by  Bruns,  of  Tubingen.  If  the  ethereal  solution  is 
used,  the  iodoform  Avill  become  diffused  over  the  entire  inner  surface  of  the 
abscess-cavity;  but,  if  a  non-evaporating  medium  for  the  mixture  is  used, 
this  must  be  done  by  gently  kneading  and  rubbing  the  parts  over  the  abscess 
after  the  cannula  is  withdrawn.  The  injection  containing  the  iodoform  is,  of 
course,  intended  to  remain  in  the  cavity.  The  puncture  in  the  skin  is  closed 
with  coUodium,  and  the  walls  of  the  abscess  are  put  in  as  close  contact  as  pos- 
sible by  compress  and  bandage.  Absolute  rest  is  to  be  enforced  for  some  time 
by  splints  or  confinement  in  bed,  according  to  the  location  of  the  abscess.  The 
operation  is  to  be  repeated  in  the  course  of  a  week,  or  as  soon  as  the  abscess- 
cavity  has  partially  refilled.  The  treatment  of  tubercular  abscesses  by  sub- 
cutaneous evacuation,  with  subsequent  lodoformization,  should  be  adopted 
and  repeated,  from  time  to  time,  in  all  cases  where  the  primary  lesion  is  in- 


516 


PEINOIPLES    OF    SUEGERY. 


accessible  to  radical  surgical  treatment,  and  may  yield  good  results  in  cases 
which  heretofore  had  been  subjected  to  heroic  surgical  treatment  from  the 
beginning.  It  may  also  prove  useful  as  a  preparatory  treatment  in  cases 
which  subsequently  require  operative  interference.  If  the  iodoform  prove 
beneficial,  seldom  more  than  three  injections  are  necessary;  the  most  re- 
liable sign  of  its  curative  effect  is  increased  viscidity  of  the  contents  of  the 
abscess  at  each  successive  tapping.  Iodoform  has  no  curative  influence  in 
tubercular  affections  complicated  by  mixed  infection  with  pus-microbes. 

Lannelongue  makes  use  of  a  10-per-cent.  solution  of  chloride  of  zinc 


Fig.  180. — Senn's  Injection-syringe. 


in  the  treatment  of  accessible  tubercular  affections.  The  injection  is  made 
not  into,  but  around,  the  tubercular  focus.  Under  strict  aseptic  precautions  , 
with  an  ordinary  hypodermic  syringe  from  5  to  15  drops  of  10-per-cent.  solu- 
tion are  injected  at  different  points  into  the  periphery  of  the  tubercular  affec- 
tion. The  reaction  is  very  prompt  and  often  intense.  In  well-selected  cases 
this  treatment  yields  excellent  results.  It  is  of  little  value  after  abscesses 
have  formed.  Ziematsky  made  use  of  this  solution  in  40  cases  of  bone  tuber- 
culosis with  very  satisfactory  results. 

(b)   Incision  and  Removal  of  Primary  Focus. — In  all  cases  where  the 


TUBEECULAR    ABSCESS.  517 

iodoform  treatment  is  inapplicable  or  has  failed,  and  where,  from  the  ana- 
tomical location  of  the  primary  lesion,  it  is  possible  to  remove  the  tuber- 
cular product  by  operative  interference,  and  the  patient  is  free  from  other 
tubercular  affections,  a  radical  operation  is  absolutely  indicated.  In  such 
cases  the  abscess-cavity  is  laid  freely  open  in  a  direction  which  will  secure 
most  ready  access  to  its  interior  with  least  injury  to  surrounding  parts. 
After  the  abscess  has  been  opened  its  contents  are  washed  away  by  irrigat- 
ing with  an  aqueous  solution  of  iodine,  after  which  the  granulations  lining 
the  cavity  are  scraped  out  with  a  sharp  spoon  and  the  primary  lesion  is 
removed  in  a  similar  manner.  In  dealing  with  such  cavities  it  is  impor- 
tant not  to  forget  that  the  granulations  contain  tubercle  bacilli,  and,  if 
they  are  not  thoroughly  removed,  the  principal  object  of  the  operation — 
removal  of  the  primary  cause- — has  not  been  accomplished,  and  a  return 
of  the  disease  is  to  be  expected.  If  the  abscess  communicate  with  a 
primary  focus  in  a  bone,  it  is  advisable  to  resort  to  ignipuncture  of  the 
bone  after  the  cavity  has  been  cleared  of  the  granulations  with  the  sharp 
spoon.  The  wound  is  then  iodoformized  and  closed  in  the  usual  manner, 
leaving  only  a  small  opening  at  the  most  dependent  point  for  drainage. 
The  scraped  surfaces  are  now  in  the  same  conditions  for  primary  union 
as  a  recent  aseptic  wound,  and,  if  kept  in  accurate  apposition  by  the  anti- 
septic dressing,  which  answers  at  the  same  time  the  purpose  of  a  compress, 
primary  union  throughout  is  frequently  obtained.  Abscesses  which  have 
opened  spontaneously,  or  during  the  treatment  of  which  infection  has 
occurred,  must  be  treated  on  the  same  principles  as  acute  abscesses.  As 
far  as  can  be  done,  the  suppurating  granulations  should  be  removed  with 
the  sharp  spoon  and  efficient  tubular  drainage  established,  and  by  fre- 
quent antiseptic  irrigations  an  attempt  is  made  to  prevent  septic  infection. 
Landerer  has  recently  called  attention  to  the  value  of  balsam  of  Peru  in 
the  treatment  of  tubercular  affections.  He  claims  that  this  drug  acts 
beneficially  by  stimulating  the  tissues  to  renewed  activity,  thus  neu- 
tralizing, at  least  to  a  certain  degree,  the  pathogenic  effect  of  the  bacilli. 
The  late  Dr.  Sayre,  of  New  York,  has  used  this  remedy  for  more  than  thirty 
years  in  the  treatment  of  tubercular  joints,  and  his  results  have  certainly  been 
extremely  satisfactory.  In  the  treatment  of  open,  suppurating,  tubercular 
cavities,  the  balsam  of  Peru  should  be  tried  as  a  local  application.  As 
a  fluid  for  irrigation  under  the  same  circumstances  nothing  can  surpass 
the  efficacy  of  a  strong  aqueous  solution  of  tincture  of  iodine  or  a  1-per-cent. 
solution  of  trichloride  of  iodine. 

(c)  General  Treatment. — Patients  suffering  from  suppurating  tuber- 
cular cavities  require  nutritious  food,  ale,  porter,  or  some  of  the  sub- 
stantial wines;  out-door  air  will  often  prove  the  best  tonic.  Change  of 
residence  to  the  sea-shore  or  some  mountain  resort  has  often  been  known 


518  PRINCIPLES    OF    SUEGERY. 

to  effect  a  cure  when  recovery  was  despaired  of  as  long  as  the  patients 
lived  in  localities  less  favorably  located.  In  the  way  of  medication  the 
treatment  must  be  purely  symptomatic.  The  prolonged  use  of  5-drop  doses 
of  guaiacol  has  a  decidedly  beneficial  effect  in  the  treatment  of  all  forms 
of  tuberculosis.  Appetite  is  restored  by  the  use  of  bitter  tonics;  anaemia 
is  treated  by  the  administration  of  some  mild  preparation  of  iron,  as  the 
syrup  of  iodide  of  iron,  tincture  of  chloride  of  iron,  albuminate  of  iron,  or 
citrate  of  iron.  If  codliver-oil  is  given  it  should  be  administered  pure, 
and  not  in  emulsion,  and  never  upon  an  empty  stomach.  The  pale  ISTor- 
wegian  oil  is  the  best.  The  best  time  to  give  the  oil,  without  disturbing 
the  digestion,  is  an  hour  or  an  hour  and  a  half  after  each  meal,  in  doses 
of  from  a  teaspoonful  to  a  tablespoonful,  according  to  the  condition  of 
the  digestion  and  the  age  of  the  patient. 

TUBERCULOSIS  OF  THE  MIDDLE  EAR. 

That  an  ordinary  otitis  media  with  perforation  of  the  tympanum 
may  occasionally  be  transformed  into  a  tubercular  lesion  by  the  entrance 
of  tubercle  bacilli  there  can  be  no  doubt.  A  number  of  cases  of  primary 
tuberculosis  of  the  middle  ear  have  been  reported  and  several  cases  have 
come  under  the  personal  observation  of  the  writer.  Habermann  has  in- 
vestigated this  subject  by  examining,  post-mortem,  18  tubercular  subjects, 
in  whom  either  otorrhoea  or  deafness,  without  active  discharge,  had  been 
observed  during  life,  and  in  9  of  these  he  could  demonstrate  the  presence 
of  tubercular  lesions  in  the  auditory  canal.  In  1  case  he  found,  in  the  left 
auditory  apparatus,  tuberculosis  of  the  entire  middle  ear  where  the  tym- 
panum was  intact.  In  another  tubercular  subject,  a  man  38  years  of  age,  in 
whom  tuberculosis  of  the  ear  was  observed  a  year  and  a  half  before  death, 
the  post-mortem  revealed  extensive  tuberculosis  of  the  cochlea,  in  the 
internal  auditory  canal,  and  in  the  superior  semicircular  canal,  while  the 
other  semicircular  canals  and  the  vestibule  were  destroyed  by  caries. 
Barnich  describes  two  forms  of  tuberculosis  of  the  middle  ear:  acute  and 
chronic.  The  former  is  of  rare  occurrence,  while  the  latter  is  very  com- 
mon. In  the  second  class  of  cases  infection  occurs  most  frequently  from 
the  naso-pharynx  through  the  Eustachian  tube.  Extension  of  a  tubercular 
otitis  media  to  the  mastoid  cells  is  a  very  common  and  serious  complica- 
tion. Infection  with  the  bacillus  tuberculosis  of  granulations  in  the 
middle  ear  through  a  perforation  in  the  tympanum  can  occur  in  persons 
otherwise  in  perfect  health.  The  diagnosis  in  such  cases  can  be  readily 
made  by  removing  fragments  of  granulation-tissue  for  microscopical  ex- 
amination. If  they  are  found  to  contain  tubercle  bacilli  a  positive  diag- 
nosis has  been  made,  and  no  time  should  be  lost  in  resorting  to  a  radical 
operation.    The  removal  of  the  infected  granulations  with  a  sharp  spoon, 


TUBEECULOSIS    OF    THE    lEIS.  519 

followed  by  irrigation  with  a  warm,  3-per-cent.  solution  of  boric  acid  and 
iodoformization  of  the  cavity  are  the  measures  to  be  employed  in  removing 
the  infected  focus  and  in  preventing  extension  of  the  disease  into  other 
parts  of  the  ear,  the  mastoid  cells,  or  the  meninges  of  the  brain.  Airol  is 
another  very  valuable  local  remedy  in  such  cases.  In  operations  on  the 
mastoid  for  tuberculosis  great  care  is  necessary  to  avoid  injuring  the  facial 
nerve.  The  author  has  seen  a  number  of  cases  in  which  permanent  facial 
paralysis  followed  the  operation — one  case  in  his  own  practice. 

TUBEECULOSIS    OF   THE    lEIS. 

Inoculations  of  the  anterior  chamber  of  the  eye  with  tubercular  ma- 
terial have  shown  the  extreme  susceptibility  of  the  iris  to  tubercular 
infection.  That  this  structure  should  occasionally  become  the  seat  of 
primary  infection  is  evident  from  a  case  reported  by  Griffith.  The  patient 
was  a  female  child  7  months  old.  The  eye  had  been  affected  for  one 
month;  there  was  an  enlarged  gland  in  the  neck  on  the  same  side,  but 
there  were  no  other  physical  signs  of  tubercle;  no  history  of  heredity.  A 
yellowish  nodule  grew  from  the  periphery  of  the  iris  of  the  right  eye, 
and  numerous  millet-seed-like  bodies  from  its  surface;  the  pupil  was 
closed,  but  there  was  no  acute  inflammation.  The  local  disease  increased 
rapidly  in  extent.  The  eye  was  enucleated  after  three  weeks'  treatment. 
The  disease  was  found  to  be  confined  to  the  iris  and  ciliary  body.  Under 
the  microscope  the  new  growth  showed  the  characteristic  structure  of 
tubercle.  In  32  recorded  cases,  in  which  microscopical  and  bacteriological 
tests  left  no  doubt  as  to  the  tubercular  nature  of  the  disease,  only  1  eye 
was  affected  in  29.  The  average  age  of  the  patients  was  12  years;  young- 
est, 4  months;  oldest,  51  years.  In  10  cases  bacilli  were  searched  for,  but 
only  found  in  4;  in  1  of  the  remaining  6  cases,  however,  the  inoculation 
test  was  successful.  A  number  of  patients  recovered  completely  and  per- 
manently after  enucleation. 

If  the  tubercle  is  located  on  the  anterior  surface  of  the  iris,  a  diag- 
nosis can  usually  be  made  without  much  difficulty  at  an  early  stage,  as 
the  inflammatory  product  can  be  seen  and  carefully  examined  through  the 
transparent  cornea.  If  some  doubt  exist  at  first  regarding  the  nature  of 
the  swelling,  this  is  soon  set  aside  by  the  progress  of  the  disease.  The 
primary  nodule  soon  becomes  surrounded  and  covered  by  an  eruption  of 
miliary  tubercles.  The  disease  here,  as  elsewhere,  shows  its  characteristic 
clinical  feature:  progressive  extension,  affecting  all  the  structures  con- 
tiguous to  or  continuous  with  the  part  primarily  affected,  irrespective  of 
their  anatomical  structure.  Glandular  infection  on  the  same  side  is  an 
early  and  quite  constant  occurrence.  Even  if  the  disease  is  correctly 
diagnosticated  at  an  early  stage,  complete  removal  by  iridectomy  as  a  cura- 


520  PEINOIPLES    OF    SURGERY. 

tive  measure  is  impossible,  as  parts  of  the  iris  which  present  a  perfectly  nor- 
mal appearance  may  already  be  infected  and  lead  to  an  almost  certain  recur- 
rence of  the  disease.  Enucleation  of  the  affected  eye  is  only  Justifiable  if  the 
disease  affect  only  one  eye,  and  if  the  surgeon  can  satisfy  himself  that  the 
patient  is  not  suffering  at  the  same  time  from  tuberculosis  in  other  organs 
inaccessible  to  successful  surgical  treatment. 

TUBERCULOSIS    OF   THE    SKUsT. 

Nearly  all  forms  of  primary  tuberculosis  of  the  skin,  as  far  as  we  know, 
are  the  result  of  direct  inoculation  with  tubercle  bacilli.  Considering  the 
frequency  with  which  abrasions  occur  in  the  exposed  portion  of  the  skin,  and 
the  innumerable  sources  of  infection  with  the  virus  of  tuberculosis,  it  is  some- 
what strange  that  primary  tubercular  lesions  of  the  skin  are  not  of  more  fre- 
quent occurrence.  Baumgarten  believes  that  this  is  due  to  the  slow  growth 
of  the  bacillus  and  the  dense  structure  of  the  deeper  portions  of  the  skin: 
conditions  which  enable  the  superficial  wound  to  heal  before  the  tubercle 
bacilli  have  penetrated  the  tissues  to  a  sufficient  depth.  Considerable  con- 
fusion exists  at  the  present  time  in  reference  to  the  nomenclature  of 
primary  tubercular  affections  of  the  skin.  We  find  descriptions  of  what 
is  called  tuberculosis  of  the  skin,  tuberculosis  verrucosa  cutis,  and  lupus, 
all  of  which  affections  have  been  proved  to  be  tubercular  in  their  origin 
and  manifesting  the  same  clinical  tendencies.  It  is  tiine  that  these  imma- 
terial and  unimportant  distinctions  should  he  set  aside,  amd  these  different 
affections  should  he  included  under  one  head,  as  primary  tuberculosis  of 
the  skin,  since  all  of  them  present  the  same  histological  structure,  and  all 
are  caused  by  direct  inoculation  ivith  tubercle  bacilli. 

'  Eiehl  and  Paltauf  have  described  an  affection  of  the  skin,  under  the 
name  of  tuberculosis  verrucosa  cutis,  in  which  the  bacillus  of  tuberculosis 
is  constantly  found,  and  which  they  attributed  to  local  infection,  because 
all  of  the  jDatients  they  examined  were  persons  handling  animal  products. 
Eiehl  has  also  shown  the  tubercular  nature  of  papillomatous  affections 
occurring  upon  the  hands  of  pathological  anatomists  by  finding  the  bacil- 
lus in  the  tissues. 

Anatomical  and  Clinical  Proofs  of  the  Tubercular  Nature  of  Lupus. — 
Lupus  vulgaris,  and  probably  the  other  varieties  of  this  affection  of  the 
skin,  are  nothing  more  nor  less  than  cases  of  cutaneous  inoculation- 
tuberculosis.  It  is  well  known  that  lupus  occurs  most  frequently  in  parts 
of  the  body  most  exposed  to  injury  and  infection;  that  is,  in  the  skin 
not  protected  by  the  hair  or  clothing.  Lupus  attacks  most  frequently  the 
nose,  face,  eyelids,  ears,  and  hands:  localities  where  abrasions  occur  most 
frequently,  and  parts  upon  which  floating  microbes  are  too  liable  to  be- 
come deposited,  and  where  direct  inoculation  with  soiled  hands,  handker- 


TUBEECULOSIS    OF    THE   SKIN.  521 

chiefs,  and  towels  is  most  likely  to  occur.  I  shall  quote  from  a  number  of 
reliable  authorities  at  sufficient  length  to  prove  that  lupus  and  tuberculo- 
sis are  identical  affections.  From  a  clinical  stand-point  Hebra  brought 
the  different  varieties  of  lupus  under  one  common  head.  He  separated  it 
entirely  from  syphilis,  but  otherwise  did  little  to  fix  its  pathological  signifi- 
cance. He  adopted  the  classification  of  Fuchs  and  the  older  French  and 
English  authors,  who  taught  that  it  was  one  of  the  manifestations  of 
scrofula,  and  that  anatomically  it  was  composed  of  granulation-tissue. 

Virchow  classified  it  with  the  granulomata,  but  denied  its  identity 
with  scrofula.  Eindfleisch  described  it  as  a  proliferation  of  epithelial 
cells:  as  a  sort  of  plitMsis  cuta;nea.  Hueter,  who,  in  his  pathological  views, 
was  generally  far  ahead  of  his  time,  affirmed  that  it  was  a  form  of  fungous 
inflammation,  the  specific  cause  of  which,  when  introduced  into  the  organ- 
ism, produced  miliary  tuberculosis.  Volkmann  included  it  among  the 
affections  which  anatomically  are  represented  by  granulation-tissue. 
Friedlander  was  the  first  to  take  a  positive  stand  in  asserting  that  lupus 
is  a  tubercular  affection  of  the  skin,  and  showed  its  histological  identity 
with  other  recognized  forms  of  local  tuberculosis.  He  demonstrated  the 
presence  of  miliary  tubercles  in  it.  The  absence  of  caseation  in  lupus, 
which  was  regarded  by  some  authors,  among  them  Baumgarten,  as  an 
evidence  of  its  non-tubercular  character,  has  been  explained  by  Schtiller 
as  being  due  i^o  the  soil  present  in>  and  around  the  nodules.  He  also  calls 
attention  to  the  fact  that  Cohnheim  and  Thoma  have  seen  caseous  foci 
in  lupus,  and  consequently  asserts  that  the  absence  of  caseation  is  no 
proof  of  the  non-tubercular  nature  of  lupus. 

ISTeisser  accepts  fully  and  pleads  strongly  in  favor  of  the  tubercular 
nature  of  lupus.  Eassdnitz  collected  209  cases  of  lupus,  and  found  that  in 
30  per  cent,  of  all  the  cases  it  was  associated  with  other  evidences  of 
tuberculosis.  He  placed,  also,  great  importance  on  the  observations  that 
lupus  is  prone  to  develop  in  the  scar  left  after  healing  of  a  localized  tuber- 
culosis .in  lymphatic  glands,  and  that  lupus  is  often  observed  upon  the 
nose  or  eyelids  in  cases  of  chronic  nasal  or  conjunctival  catarrh.  In  10 
to  15  per  cent,  of  his  cases  lupus  could  be  traced  to  hereditary  predis- 
position. Demme  observed  miliary  tuberculosis  in  2  of  his  cases  after 
scraping  lupus.  Pontoppidan  asserted  that,  in  his  experience,  50  to  75 
per  cent,  of  patients  suffering  from  lupus  manifested  additional  evidences 
of  tuberculosis.  Quinquaud  saw  in  3  cases  of  lupus  pulmonary  tubercu- 
losis appear  as  a  final  cause  of  death.  Of  38  cases  that  came  to  the  per- 
sonal knowledge  of  Bessnier,  8  of  them  suffered  from  pulmonary  phthisis. 
Of  2  patients  treated  by  Aubert,  1  died  of  acute  pulmonary  tuberculosis 
and  the  other  of  tubercular  pleuritis  after  scarification. 

Eenoward  was  able  to  ascertain  the  existence  of  pulmonary  phthisis 


523  PEINCIPLES    OF    SUEGERY. 

in  50  per  cent,  of  his  cases  of  lupus.  Block  met  with,  tuberculosis  in  other 
organs^  before  or  after  the  development  of  lupus,  in  114  out  of  144  cases. 
Bender  examined  374  cases  of  lupus.  In  159  of  these  an  accurate  history 
could  not  be  obtained.  In  99  of  the  latter  number  symptoms  of  other 
antecedent  or  coexisting  tubercular  lesions  existed.  In  77  of  the  cases 
tuberculosis  in  an  etiological  or  clinical  aspect  was  present.  Leloir  ob- 
served several  cases  in  which,  after  years,  a  lupus  of  the  face  gave  rise 
to  a  pseudoerysipelatous  swelling  of  the  face,  which  disappeared  after  a 
time,  to  be  followed  by  swelling  of  the  submaxillary  lymphatic  glands, 
which  remained  stationary.  Soon  after  the  affection  of  the  lymphatic 
glands  had  apjDcared,  febrile  disturbances,  gastric  symptoms,  and  evi- 
dences of  pulmonary  infiltration  followed.  In  all  of  these  cases  Leloir  be- 
lieves that  the  virus  of  tuberculosis  had  left  the  primary  location,  and 
had  migrated  through  the  lymphatic  vessels  and  glands  into  the  lungs. 
In  10  out  of  his  17  cases  the  tubercular  nature  of  lupus  was  clinically 
manifest.  Sachs  ascertained  that,  of  105  cases  of  lupus  which  he  collected, 
in  86  per  cent,  the  patients  had  coexisting  tuberculosis  in  other  parts  of 
the  body,  or  an  hereditary  predisposition  to  tuberculosis  could  be  shown 
to  exist. 

Experimental  and  Bacteriological  Evidences  of  the  Tubercular  Nature 
of  Lupus. — If  the  clinical  and  anatomical  proofs  which  have  been  ad- 
vanced to  establish  the  tubercular  nature  of  lupus  point  unequivocally  in 
that  direction,  the  crucial  test  is  furnished  by  the  inoculation  experiments 
and  bacteriological  investigations  that  have  been  made  with  the  same 
object  in  view.  Koch,  in  his  paper  on  the  etiology  of  tuberculosis,  states 
that  he  produced  a  pure  culture  of  the  bacillus  tuberculosis  from  a  case  of 
lupus  which  resembled,  in  every  respect,  the  cultures  obtained  from  recog- 
nized tuberculosis,  and  with  the  fifteenth  generation  from  this  source, 
one  year  after  the  first  cultivation,  he  inoculated  5  guinea-pigs  by  sub- 
cutaneous injection  and  produced  typical  tuberculosis  in  all  of  them. 
Doutrelepont  found  in  7  cases  of  lupus  the  bacillus  tuberculosis  invariably 
present,  in  greater  or  less  number,  either  within  the  cells  or  dispersed  in 
small  groups  between  them.  He  never  found  them  in  the  interior  of 
giant-cells,  but  in  their  immediate  vicinity.  In  a  second  communication 
the  same  author  reports  18  additional  cases  of  lupus,  in  each  of  which  the 
presence  of  the  bacillus  could  be  demonstrated  in  the  tissues.  Desime 
detected  the  bacillus  in  6  cases  of  lupus.  Pfeiffer  found  it  in  a  case  of 
lupus  of  the  conjunctiva.  Schuchardt  and  Krause  discovered  the  bacillus 
in  3  cases  of  lupus  affecting,  respectively,  the  face,  ears,  and  leg.  In 
examinations  made  of  11  cases  of  lupus  by  Cornil  and  Leloir,  and  4  by 
Koch,  for  the  especial  purpose  of  showing  the  identity  of  lupus  and 
tuberculosis,  the  bacillus  was  found  in  every  instance.     In  the  artificial 


TUBEECULOSIS    OF    THE    SKIN.  523 

tuberculosis  of  animals,  produced  by  implantation  of  lupous  tissue,  the 
specific  microbe  was  shown  to  exist  by  Pagenstecher,  Pfeiffer,  Koch,  and 
Doutrelepont.  To  proye  that  lupus  and  tuberculosis  are  identical,  it  be- 
came necessary  to  furnish  the  necessary  experimental  proof,  and  to  show 
the  uniform  presence  of  the  bacillus  of  tuberculosis  in  the  lupous  tissue, 
all  of  which  has  been  done  with  almost  infallible  positive  results.  The 
inoculation  experiments  with  lupous  tissue  have  already  been  referred  to, 
and  from  them  it  can  be  learned  that,  with  few  exceptions,  they  were 
followed  by  positive  results;  that  is  to  say,  implantation  of  lupous  tissue 
into  subcutaneous  tissue  or  the  peritoneal  cavity,  in  animals  susceptible 
to  tuberculosis,  gave  rise  to  local  tuberculosis  at  the  point  of  implantation 
and  to  dissemination  of  the  process  in  a  manner  characteristic  of  tubercu- 
losis in  man.  A  difEuse  tuberculosis  of  the  skin  and  mucous  membranes, 
occurring  as  a  sort  of  secondary  localization  in  patients  suffering  from  ad- 
vanced tuberculosis,  has  been  recently  described  by  Pantlen,  Bizzozero, 
Baumgarten,  Chiari,  Hall,  Janisch,  Eiehl,  Yidal,  and  Finger.  As  such 
cases  occur  in  consequence  of  autoinfection  in  persons  debilitated  by  the 
ravages  of  the  primary  disease  in  the  lungs,  it  is  not  surprising  that  the 
skin  affection  should  extend  more  rapidly  than  in  cases  of  primary  tuber- 
culosis of  the  skin. 

Pathology  and  Morbid  Anatomy. — As  every  case  of  tuberculosis  of 
the  skin  is  caused  by  the  entrance  of  tubercle  bacilli  from  without  through 
some  infection-atrium,  the  primary  pathological  changes  occur  at  the 
point  of  inoculation.  As  soon  as  the  bacilli  reach  the  vascular  layers  of 
the  skin,  a  nodule  forms  which  contains  the  histological  elements  de- 
scribed in  the  section  on  the  "Histology  of  Tubercle."  By  the  formation 
of  new  nodules,  a  more  diffuse  cellular  infiltration  of  the  tissue  between 
them,  the  lesion  tends  to  spread,  and,  by  confluence  of  the  infiltrated  por- 
tions, a  dense  and  more  or  less  extensive  area  of  nodular  infiltration  may 
be  formed.  If  the  continuity  of  the  epidermic  layer  of  the  skin  has  been 
restored  after  infection  has  occurred,  and  the  cell-proliferation  has  been 
abundant,  the  swelling  may  resemble  a  papillomatous  growth,  and,  on  ac- 
count of  the  increased  vascular  supply,  an  excessive  production  and  ex- 
foliation of  epidermis  over  the  infiltrated  area  occur.  These  are  the  eases 
of  inoculation-tuberculosis  which  have  been  described  as  tuberculosis 
verruoosa  cutis.  The  nodules  undergo  disintegration  near  the  centre,  and 
the  epidermis  at  a  corresponding  point  becomes  macerated  and  detached, 
leaving  at  first  a  minute  defect,  which  secretes  a  serous  fluid. 

As  soon  as  the  underlying  granulation-tissue  has  been  exposed  to  in- 
fection from  without,  infection  with  pus-microbes  occurs,  and  the  destruc- 
tion of  tissue  is  hastened  by  the  suppurative  inflammation  which  follows, 
as  the  granulation-cells  are  rapidly  destroyed  by  the  pus-microbes  and 


524  PBINCIPLES    OF    SUEGEEY. 

their  toxins,  and  are  eliminated  as  pus-corpuscles.  Ulceration  now  takes 
the  place  of  the  papillomatous  growths^  and  the  defect  increases  in  size 
as  rapidly  as  granulation-tissue  is  produced  by  the  action  of  the  bacillus 
tuberculosis.  New  nodules  are  produced  in  the  immediate  vicinity  of  the 
ulcer,  which  are  again  dissolved  by  retrograde  tissue-metamorphosis  of  its 
cellular  constituents  and  purulent  liquefaction.  It  is  not  uncommon  to 
find,  at  some  places,  efforts  at  repair,  and  even  partial  cicatrization  and 
epidermization;  but  the  disease  pursues  its  relentless  course  in  other  di- 
rections, and,  after  what  appears  as  healthy  new  tissue,  becomes  again 
infected  and  the  process  of  destruction  is  rejaeated.  In  some  forms  of 
tuberculosis  of  the  skin  the  infection  remains  superficial,  and  only  the 
more  superficial  portions  of  the  skin  undergo  pathological  changes  charac- 
teristic of  tuberculosis;  while  in  other  cases  the  process  extends  deeper 
and  deeper,  until  muscles,  fascia,  and  bone  are  destroyed  by  the  disease,  in 
the  manner  of  its  extension  from  tissue  to  tissue  resembling,  in  this  respect, 
the  clinical  behavior  of  malignant  tumors.  In  this  manner  the  whole  nose, 
eyelids,  and  the  greater  portion  of  the  face  are  frequently  destroyed  before 
the  patient  is  relieved  from  his  sufferings  by  a  merciful  death.  Microscopical 
examination  shows  the  lesions  to  consist  in  the  formation  of  granulation- 
tissue,  in  which  the  typical  structure  and  histological  elements  of  tubercle 
can  be  readily  recognized.  Caseation  is  seldom  found,  probably  on  ac- 
count of  the  location  of  the  tubercular  product  so  near  the  surface  of  the 
skin,  and  also  because  the  granulation-tissue  soon 'becomes  the  seat  of  a 
secondary  infection  with  microbes  which  prevent  caseation.  In  most  cases 
a  well-marked  reticulum  is  present  between  the  new  cells,  and  these  are 
often  grouped  in  masses  around  the  blood-vessels. 

Symptoms  and  Biagnosis. — Tuberculosis  of  the  skin  is  most  frequently 
met  with  in  middle-aged  persons,  but  no  age  is  exempt  from  it,  as  I  have 
seen  it  in  children  5  years  of  age  and  in  persons  far  advanced  in  years. 
It  attacks  most  frequently  the  nose,  eyelids,  cheeks,  ears,  and  hands,  but 
it  may  also  develop  upon  the  different  parts  of  the  trunk.  The  disease 
commences  in  the  form  of  a  small,  red,  vascular  nodule;  is  not  painful 
nor  tender  on  pressure.  In  the  vicinity  of  this  nodule  new  foci  spring  up, 
and  by  confluence  may  form  a  swelling  of  considerable  size.  To  the  touch 
these  nodules  impart  rather  a  sensation  of  elasticity  than  hardness,  and  if 
the  swelling  is  large  in  size  an  obscure  sense  of  fluctuation  may  be  fel1« 
Before  ulceration  takes  place  the  surface  of  the  nodules  is  covered  by  a 
thickened  epidermis,  which  can  be  scraped  off  in  white  scales.  If  no  ulcer- 
ation take  place  {lupus  non-exedens),  the  nodules  may  remain  stationary 
in  size  for  an  indefinite  period  of  time  or  undergo  a  spontaneous  cure  by 
cicatrization,  during  which  the  epithelioid  cells  are  converted  into  con- 
nective tissue.    Ulceration  begins  over  the  centre  of  the  nodule,  at  a  point 


TUBEECULOSIS    OF    THE    SKIN.  525 

where  the  nutrition  of  the  tissues  is  most  impaired  by  pressure^  and  ex- 
tends from  here  toward  the  margins  of  the  nodule,  attacking  the  new 
nodules  almost  as  fast  as  they  are  formed  (lupus  exedens).  Cicatrization 
and  ulceration  are  often  seen  side  by  side.  Ulceration  is  hastened  by  the 
secondary  infection  with  pus-microbes,  which  invade  the  granulation- 
tissue  in  the  margins  of  the  ulcer,  occupying  the  tubercular  zone.  Eepair 
by  cicatrization  and  epidermization  is  more  likely  to  occur  if  the  infection 
remains  superficial,  but  is  usually  entirely  absent  as  soon  as  the  tubercular 
process  has  extended  beyond  the  limits  of  the  skin.  The  differential  diag- 
nosis as  to  tuberculosis  of  the  skin,  tertiary  syphilis,  and  epithelioma  is 
generally  very  difficult,  and  sometimes  almost  impossible.  There  is  very 
little  difference  between  the  histological  structure  of  a  tubercle-nodule 
and  a  gumma,  and  the  most  experienced  microscopist  is  liable  to  make  a 
mistake  if  called  upon  to  make  a  diagnosis  exclusively  by  the  use  of  the 
microscope. 

The  history  of  the  case  is  of  the  greatest  importance  in  making  a 
differential  diagnosis  between  tuberculosis  and  syphilis.  If  the  patient  is 
positive  that  he  never  contracted  syphilis,  it  is  still  possible  that  the 
lesion  may  be  syphilitic,  as  the  disease  may  have  been  inherited;  if  he 
give  a  history  of  primary  and  secondary  syphilis,  the  affection  may  still 
be  tubercular;  but  a  straight  history  of  tuberculosis  or  syphilis  will  go  far 
in  determining  the  nature  of  the  local  affection.  If  any  doubt  remain 
this  can  be  cleared  up  by  the  use  of  the  microscoj^e,  and,  if  this  fail,  in 
the  course  of  five  weeks,  either  by  the  effect  produced  by  antisyphilitic 
treatment  or  the  result  of  inoculation  experiments  made  by  implantation 
of  fragments  from  the  inflamn^atory  product  into  the  subcutaneous  tissue 
in  guinea-pigs.  The  microscopical  examination  of  fragments  of  tissue  re- 
moved for  this  purpose  must  have  in  view  the  detection  of  the  bacillus 
of  tuberculosis,  which  is  constantly  present  in  tubercular  tissue.  The 
specimen  must  be  prepared  by  double  staining  according  to  Ehrlich's 
method,  and,  if  the  affection  is  tubercular,  the  bacillus  can  be  found  by 
making  a  patient  search  for  it;  if  it  is  syphilitic,  it  will,  of  course,  be 
absent.  The  bacilli,  however,  may  be  so  few  that  even  a  careful  search 
of  stained  specimens  may  result  negatively,  and  in  such  a  case  a  positive 
diagnosis  can  often  be  made  by  observing  the  effects  of  a  thorough  anti- 
syphilitic  treatment.  For  an  adult,  ^/^^  grain  of  corrosive  sublimate  with 
15  grains  of  potassic  iodide,  dissolved  in  distilled  water,  is  given  four  times 
a  day, — after  each  meal  and  at  bed-time.  If  the  lesion  is  syphilitic,  a  de- 
cided improvement  will  be  observed  in  the  course  of  two  or  three  weeks; 
if  tubercular,  this  treatment  will  make  no  decided  impression  on  the  local 
lesion.  The  most  reliable  diagnostic  test  in  differentiating  between  tuber- 
culosis of  the  skin  and  a  syphilitic  lesion  consists  in  removing,  under  aseptic 


526  PEINCIPLES    OF    SUKGERY. 

precautions,  a  fragment  of  granulation-tissue  the  size  of  a  small  pea,  and  im- 
planting the  same  into  the  subcutaneous  tissue  of  a  guinea-pig. 

Tavel  has  been  studying,  in  a  systematic  manner,  the  diagnostic  value 
of  implantations  of  tubercular  material  in  animals,  mainly  guinea-pigs.  He 
found  that  fragments  of  granulation-tissue,  taken  from  a  tubercular  product 
and  implanted  into  the  subcutaneous  connective  tissue  in  the  inguinal  re- 
gion in  guinea-pigs,  invariably  produces  in  this  animal  local,  and  later  gen- 
eral, miliary  tuberculosis,  and  death  in  from  five  to  six  weeks.  The  course 
of  the  disease  thus  artificially  produced  is  typical;  at  the  point  of  inocula- 
tion a  hard  nodule  appears  first,  the  result  of  traumatic  response  on  the  part 
of  the  tissues  around  the  graft.  Next,  a  lymphatic  gland  becomes  enlarged 
in  the  immediate  vicinity  of  the  inoculation  and  in  the  direction  of  the  lym- 
phatic stream.  Often  all  of  the  inguinal  glands  are  infected  successively. 
At  a  later  stage  the  axillary  glands  become  affected.  At  the  necropsy  it  was 
always  observed  that,  of  the  internal  organs,  the  spleen  becomes  affected 
first,  then  the  liver  and  lungs;  but  before  death  is  produced  almost  every 
organ  is  the  seat  of  miliary  nodules.  When  the  differential  diagnosis  be- 
tween tuberculosis  and  syphilis  cannot  be  made  from  a  clinical  study  of  the 
case  or  by  the  use  of  the  microscope,  inoculation  experiments  will  always 
furnish  the  desired  information  in  from  three  to  six  weeks.  If  the  lesion  is 
tubercular,  the  infected  guinea-pig  contracts  the  disease,  and  dies  in  from 
five  to  six  weeks;  if  it  is  syphilitic,  the  implantation  will  prove  harmless  and 
the  animal  remains  well.  The  differential  diagnosis  between  tuberculosis 
of  the  skin  and  epithelioma  must  be  based  on  the  primary  location  of  the 
pathological  product  and  the  character  of  the  infiltration.  Tuberculosis 
commences  in  the  vascular  portion  of  the  skiji;  hence,  the  primary  nodule  is 
subepidermal;  while  epithelioma  starts  in  the  non-vascular  epidermis  and 
infiltrates  the  deeper  layers  of  the  skin  later.  The  tubercular  nodule  is  not 
hard,  but  somewhat  elastic,  to  the  touch.  The  carcinomatous  infiltration 
feels  almost  as  hard  as  cartilage,  and  forms  a  part  of  the  epithelial  layer  of 
the  skin  from  the  beginning.  A  tubercular  ulcer  of  the  skin  is  covered  with 
flabby  granulations,  and  its  miargins,  although  infiltrated,  do  not  feel  as  firm 
as  the  borders  of  an  ulcerating  epithelioma.  Under  the  microscope  the  tu- 
bercle-nodule shows  granulation-cells  in  the  meshes  of  a  delicate  reticulum, 
while  in  a  section  of  an  epithelioma  a  well-marked  alveolated  reticulum  can 
be  seen,  the  meshes  of  which  are  occupied  by  embryonal  epithelial  cells  ar- 
ranged in  concentric  layers.  Another  microscopical  criterion  is  the  absence 
of  blood-vessels  in  tubercle-nodules,  while  carcinoma  is  a  vascular  structure. 

Prognosis. — Primary  local  tuberculosis  of  the  skin  may  lead  to  gland- 
ular infection,  and,  after  the  last  lymphatic  filter  has  been  passed,  to  gen- 
eral miliary  tuberculosis.  The  tubercular  product  in  exceptional  cases  be- 
comes the  starting-point  of  carcinoma.     The  local  extension  of  the  tuber- 


TUBEECULOSIS    OF    THE    SKIN.  537 

cular  process  is  subject  to  many  variations.  In  some  instances  the  process 
commences  during  early  life,  and  remains  stationary  for  twenty  or  more 
years,  when  it  suddenly  commences  to  extend  very  rapidly,  destroying  all 
of  the  tissues  which  come  in  its  way,  irrespective  of  their  anatomical  struct- 
ure. Tuberculosis  of  the  face,  manifesting  such  a  tendency  to  rapid  exten- 
sion, may  in  a  few  months  destroy  nearly  all  of  the  soft  tissues  and  a  con- 
siderable portion  of  the  superficial  bones,  so  that  the  head  looks  more  like 
a  skull  than  the  head  of  a  living  being.  In  other  instances  the  ulceration 
keeps  extending,  while  at  other  points  the  healing  process  is  progressing  with 
equal  speed.  In  such  cases  the  massive  scars  are  often  productive  of  the 
most  hideous  deformities.  Eecurrence  of  the  disease  in  the  scar-tissue  is  of 
common  occurrence.  The  prognosis,  as  far  as  life  is  concerned,  is  favorable 
so  long  as  the  disease  remains  local  and  does  not  progress  rapidly;  while  life 
is  threatened  as  soon  as  regional  infection  through  the  lymphatic  glands 
takes  place,  or  when  ulceration  extends  rapidly  without  any  tendency  to  re- 
pair by  cicatrization  and  epidermization.  Tuberculosis  of  the  skin  without 
ulceration  is  a  more  benign  form  of  the  disease  than  when  ulceration  has 
occurred,  as  in  the  latter  case  the  destructive  process  is  hastened  by  second- 
ary infection  with  pus-microbes. 

Treatment. — About  the  only  medicine  that  deserves  any  confidence  in 
the  treatment  of  tuberculosis  of  the  skin  is  arsenic.  This  drug  can  be  given 
in  the  form  of  Fowler's  solution,  in  doses  of  from  3  to  10  drops  after  each 
meal,  well  diluted  with  water.  It  is  best  to  commence  with  the  smallest 
dose  and  add  1  drop  every  week  until  the  physiological  effect  is  produced, 
when  the  use  of  the  medicine  is  not  suspended,  but  the  dose  is  diminished. 
To  be  of  any  use,  the  medicine  has  to  be  continued  for  weeks  and  months. 
If  the  patient  is  angemic,  it  is  combined  with  the  tincture  of  chloride  of  iron, 
and,  if  the  patient's  appetite  is  poor,  with  one  or  more  of  the  bitter  tonics. 
If  the  patient  is  emaciated,  pure  codliver-oil  can  be  given  with  good  results 
an  hour  and  a  half  after  meals,  in  doses  which  will  be  tolerated  by  the 
stomach.  If  digestion  is  impaired  this  drug  should  be  withheld.  A  well- 
selected,  nutritious  diet  is  indicated  in  all  such  cases,  with  plenty  of  out- 
door exercise.  Salt-water  baths  invigorate  the  peripheral  circulation,  and 
consequently  favor  the  limitation  of  the  disease  and  the  process  of  repair. 
The  surgical  treatment  of  tuberculosis  of  the  skin  is  to  be  conducted  upon 
the  same  principles  as  operations  for  the  removal  of  malignant  tumors.  The 
use  of  caustics  often  does  more  harm  than  good.  The  great  object  of  the  local 
treatment  is  to  remove  every  particle  of  the  infected  tissues,  for  if  this  is  not 
done  a  recurrence  is  almost  sure  to  tahe  place.  If  the  patient  object  to  a 
radical  operation,  and  the  tubercular  process  has  gone  on  to  ulceration,  all 
irritating  applications  should  be  avoided  and  the  ulcer  protected  by  a  piece 
of  lint  spread  with  empl.  hydrargyri  or  unguent,  hydrargyri  oxyd.  albi.    Bal- 


628  rEINCIPLES    OF    SURGERY. 

salni  of  Pern  can  also  be  used  with  benefit  as  a  local  application.  If  a  radical 
operation  is  decided  upon,  this  should  be  done  preferably  by  excision.  Ex- 
cision should  be  practiced  exclusively  in  cases  where  the  extent  of  the  disease 
is  limited.  The  incisions  should  be  made  some  distance  from  the  visible 
margins  of  the  infiltration,  in  order  to  include  tissues  which,  although  pre- 
senting macroscopically  a  healthy  appearance,  may  already  be  infected  with 
bacilli,  conveyed  there  by  migrating  leucocytes.  The  greatest  care  must  be 
exercised  in  removing  the  deeper  portions  of  the  inflammatory  product,  as 
this  may  send  down  projections  at  different  points  which  it  becomes  neces- 
sary to  remove  with  the  principal  mass. 

Thiersch's  method  of  restoring  the  excised  skin  places  the  surgeon  in  a 
position  where  he  can  excise  an  extensive  area  of  integument,  and  yet  obtain 
primary  healing  of  the  wound  and  perfect  restoration  of  the  skin  under  a 
single  dressing.  I  have,  on  several  occasions,  removed  tubercular  foci  from 
the  face  and  temporal  region  the  size  of  the  palm  of  the  hand,  and,  by  cov- 
ering the  defect  at  once  with  large  skin-grafts,  saw  the  whole  healing  process 
completed  in  two  weeks,  with  almost  perfect  restoration  of  the  lost  tissues. 
In  cases  where  the  disease  is  too  extensive  for  excision,  removal  of  the  in- 
fected granulations  is  attempted  by  the  vigorous  use  of  Volkmann's  sharp 
spoon.  Skin-grafting  can  be  done  after  curetting  in  the  same  manner  as 
after  excision,  but  the  knife  always  leaves  a  better  surface  for  skin-grafting 
than  the  sharp  spoon.  If,  after  either  operation,  the  result  is  not  perfect, 
and  the  tubercular  process  returns  at  one  or  more  points,  the  granulations 
are  again  removed  with  the  sharp  spoon  and  the  defect  covered  with  skin- 
grafts.  Tuberculosis  without  ulceration  demands  treatment  by  excision, 
while  in  the  case  of  ulcerating  nodules  the  choice  lies  between  the  knife  and 
sharp  spoon,  and  to  the  first  preference  should  be  given  in  all  cases  where 
excision  can  be  done  Avith  a  fair  prospect  of  removing  all  of  the  infected 
tissues.  The  constitutional  treatment  should  be  continued  for  several 
months  after  the  local  lesion  has  apparently  healed,  as  the  disease  is  very 
liable  to  recur  at  the  site  of  operation.  The  site  of  operation  should  be  care- 
fully protected  against  injury  a  long  time  after  the  process  of  repair  has 
been  completed,  in  order  to  guard  against  a  return  of  the  disease,  from  local 
irritation  preparing  the  soil  for  the  pathogenic  action  of  latent  bacilli  which 
may  remain  incorporated  in  the  scar-tissue. 

In  large  defects  of  the  skin  caused  by  the  disease  and  operation  the 
surface  can  often  be  covered  by  a  plastic  operation,  and,  when  this  is  pos- 
sible, it  should  be  preferred  to  skin-grafting,  as  the  results  are  much  more 
satisfactory. 


CHAPTEE  XXI. 

TUBEECULOSIS    OF   LYMPHATIC    GrLANDS   AXD   PeKITONEUM. 
TUBEKCULOSIS   OF   LYMPHATIC   GLANDS. 

That  most  cases  of  chronic  inflammation  of  the  lymphatic  glands  are 
— in  their  origin^,  conrse,  and  final  termination — instances  of  local  tuber- 
culosis has  been  satisfactorily  shown  by  clinical  experience,  microscopical 
examination,  inoculation,  and  cultivation  experiments. 

Manner  of  Infection  and  Dissemination  of  the  Bacillus  of  Tuberculosis. 
— The  tubercle  bacilli  enter  the  lymphatic  circulation  through  some  abrasion 
or  pathological  defect  of  the  skin  or  mucous  surface;  any  loss  of  continuity 
of  surface  may  furnish  the  necessary  portio  invasionis  for  the  entrance  of 
the  microbes  from  without.  Tuberculosis  of  the  cervical  lymphatic  glands 
occurs  most  frequently  by  infection  through  the  tonsils,  naso-pharynx,  or 
diseased  alveoli  of  the  maxillary  bones.  De  Mochowski  found  that  the  mu- 
cous membrane  of  the  naso-pharynx  is  diseased  in  31  out  of  64  tubercular 
patients.  Stark  believes  that  carious  teeth  are  the  most  common  source  of 
infection.  Mcoll  studied  500  cases  of  tuberculosis  of  the  lymphatic  glands 
of  the  neck  and  ascertained  that  the  glands  over  the  sheath  of  the  large  ves- 
sels on  a  level  with  the  bifurcation  of  the  carotid  artery  are  generally  first  af- 
fected. In  70  per  cent,  of  the  cases  the  disease  was  bilateral.  The  author 
has  seen  a  number  of  cases  of  tuberculosis  of  the  axillary  gland  secondary 
to  a  similar  affection  of  the  glands  of  the  neck;  very  rarely  as  a  primary 
affection.  The  inguinal  glands  are  occasionally  involved  primarily,  and  there 
is  good  reason  to  assume  that  infection  takes  place  through  the  external 
genital  organs.  Tuberculosis  of  joints  and  bones  seldom  gives  rise  to  glandu- 
lar tuberculosis.  An  interesting  case  of  this  kind  came  recently  under  my 
observation  in  which  progressive  tubercular  lymphadenitis  of  the  left  groin 
followed  chronic  tuberculosis  of  the  knee-joint  on  the  corresponding  side 
(Fig.  181).  In  tubercular  affections  of  the  skin  the  point  of  inoculation 
becomes  the  centre  of  the  primary  nodule,  because  the  bacilli  are  present  in 
sufficient  quantity  and  virulence  to  produce  the  necessary  irritation;  but  in 
tuberculosis  of  the  lymphatic  glands  the  microbes  enter  the  lymphatic  chan- 
nels usually  before  they  have  caused  any  visible  lesions  at  the  point  of  en- 
trance. 

Volkmann  found  tubercle  bacilli  in  the  skin  of  an  eczematous  fore- 
arm, and  it  is  probable  that  many  cases  of  tuberculosis  of  the  cervical  glands 
in  children  are  caused  by  the  entrance  of  tubercle  bacilli  through  an  eczem- 
atous patch  on  the  face,  ear,  or  scalp.     In  perhaps  95  out  of  every  100 

^*  (529) 


530 


PRINCIPLES    OF    SURGERY. 


cases  of  tuberculosis  of  the  lymphatic  glands  the  disease  attacks  the  glands 
of  the  neck, — as  the  scalp,  face,  and  mouth  are  parts  of  the  body  most  fre- 
quently the  seat  of  slight  injuries  and  superficial  lesions,  and  also  most  ex- 
posed to  tubercular  infection.  The  lymphatic  glands  act  as  filters  for  the 
microbes  which  enter  the  body  through  the  lymphatic  channels.  The  patho- 
logical conditions  which  are  produced  in  the  interior  of  a  lymphatic  gland 
by  the  presence  of  pathogenic  microorganisms  are  well  calculated,  for  the 
time  being  at  least,  to  limit  the  extension  of  the  infection.  The  lymphad- 
enitis which  is  produced  blocks  the  lymph-spaces  with  the  products  of  a 
specific  inflammation,  which,  temporarily  at  least,  mechanically  obstructs 


Fig.  181.— Tubercular  Lymphadenitis  foUowing  Tuberculosis  of  the  Knee-joint. 


the  way  for  the  microbes  toward  the  general  circulation.  Primary  infection 
of  a  lymphatic  gland  by  the  bacillus  of  tuberculosis  in  many  instances  attacks 
different  portions  of  the  gland  from  the  very  beginning,  as  a  number  of  in- 
dependent centres  of  tissue-proliferation  are  established  around  each  mi- 
crobe, or  around  each  colony  of  microbes  arrested  on  their  way  through  the 
gland.  These  separate  nodules  soon  become  confluent  and  form  a  mass  of 
considerable  size,  which  soon  implicates  the  entire  parenchyma  of  the  gland. 
Local  dissemination  of  the  bacillus  of  tuberculosis  in  the  interior  of  the 
gland  is  accomplished  by  the  assistance  of  the  lymph-stream,  as  long  as  the 
microbes  remain  free,  and  through  the  medium  of  wandering  cells  as  they 


TUBEECXJLOSIS    OF    LYMPHATIC    GLANDS.  531 

have  become  attached  to  or  have  entered  the  protoplasm  of  the  lymphoid 
corpuscles  and  leucocytes. 

Eegional  infection  is  not  limited  to  the  lymphatic  glands,  on  the  proxi- 
mal^side  of  the  primary  focus,  as  during  the  course  of  the  disease  we  often 
observe  that  lymph-glands  become  involved  which  are  not  in  the  direct 
course  of  the  lymph-stream.  As  the  bacillus  of  tuberculosis  is  non-motile, 
we  can  only  explain  its  transportation  in  a  direction  opposite  the  lymph- 
current  by  its  conveyance  in  such  a  direction  by  migrating  amoeboid  cells. 
As  the  lymph-stream  is  impeded  or  perhaps  completely  arrested  by  the 
inflammatory  product  which  has  accumulated  in  the  lymph-spaces,  mi- 
gration of  leucocytes  in  an  opposite  direction  is  easily  explained.  The 
usual  course  of  infection  along  the  lymphatic  channels  is,  however, 
in  the  direction  of  the  lymph-current.  The  course  of  the  disease  is 
almost  characteristic.  A  lymphatic  gland  in  the  submaxillary  or  parotid 
region  becomes  enlarged,  and  from  this  centre  the  infection  invades 
successively  gland  after  gland,  until  the  whole  chain  of  lymphatics 
from  the  angle  of  the  lower  jaw  to  the  clavicle  has  become  involved.  An- 
other interesting  feature  is  observed  in  reference  to  the  regional  diffusion 
of  the  tubercular  process,  as  the  course  of  infection  usually  corresponds  to 
the  location  of  the  gland  first  affected.  If  the  infection  has  involved  pri- 
marily one  of  the  deep  glands  of  the  neck,  the  glands  subsequently  invaded 
belong  to  the  deep  lymphatics  which  follow  the  large  blood-vessels  of  the 
neck.  If,  on  the  other  hand,  the  primary  depot  is  located  in  one  of  the 
superficial  glands,  the  glands,  which  are  being  irrigated  by  the  lymph  that 
flows  through  and  from  the  gland,  become  the  seat  of  successive  infection, 
showing  again  that  regional  infection  usually  takes  place  in  the  direction 
of  the  lymph-current.  In  extensive  tuberculosis  of  the  glands  of  the  neck, 
the  superficial  and  deep  glands  are  affected  at  the  same  time,  the  infection 
from  one  set  of  vessels  to  the  other  being  accomplished  through  the  medium 
of  communicating  branches.  As  long  as  the  infection  has  not  extended  along 
the  entire  length  of  the  chain  of  lymphatic  glands,  the  patient  is  protected 
against  miliary  tuberculosis;  but  as  soon  as  the  virus  has  passed  all  of  the 
lymphatic  filters  it  enters  the  general  circulation,  and  diffuse  miliary  tuber- 
culosis follows  as  an  inevitable  result. 

Pathological  Histology  and  Morbid  Anatomy. — As  soon  as  a  sufficient 
number  of  bacilli  has  entered  the  parenchyma  of  a  lymphatic  gland,  a  karyo- 
kinetic  process  is  initiated  which  involves  the  parenchyma-cells,  the  cells 
of  the  reticulum,  and  the  endothelial  cells.  The  proliferating  tissue-cells 
produce  epitheloid  and  giant  cells,  while  the  lymphoid  elements  are  either 
the  normal  lymphoid  corpuscles,  which  have  remained  unaffected  by  the 
inflammatory  process,  or  leucocytes.  As  the  number  of  bacilli  present  is 
not  great,  the  process  is  a  very  slow  one,  and  the  inflammatory  product  un- 


532  PEINCIPLES    OF    SUEGEEY. 

dergoes  very  gradually  the  characteristic  degenerative  changes.  The  en- 
trance of  new  bacilli  from  the  infection-atrium  is  prevented  by  the  obstruc- 
tion in  the  lymph-spaces,  caused  by  the  accumulation  within  them  of  the 
products  of  inflammation,  which  arrests  the  lymphatic  circulation  in  the 
afferent  vessels  of  the  gland,  through  which  primarily  the  bacilli  entered. 
The  bacilli  found  in  the  tubercular  gland  are,  therefore,  derived  from  the 
multiplication  of  the  bacilli  which  originally  entered  the  gland  from  the 
primary  infection-atrium.  The  cells  that  first  undergo  coagulation-necrosis 
are  those  in  the  centre  of  each  nodule,  for  reasons  which  have  been  pre- 
viously mentioned.  As  the  products  of  coagulation-necrosis  do  not  furnish 
the  necessary  nutritive  material  for  the  growth  of  the  bacillus,  the  microbes 
gradually  disappear  in  the  centre  of  the  nodule,  while  they  can  still  be  found 
within  and  between  the  cells  in  the  surrounding  granulation-tissue.  Cell- 
necrosis  is  followed  by  caseation,  and  by  this  time  nearly  all  of  the  bacilli 
have  disappeared,  but  inoculation  experiments  with  cheesy  material  have 
shown  that  spores  remain  in  an  active  condition,  and  capable  of  reproducing 
the  disease  in  animals.  The  numerous  nodules  which  appear,  often  almost 
simultaneously,  in  the  interior  of  the  same  gland  become  confluent,  and  in 
the  course  of  time  the  entire  parenchyma  of  the  gland  is  destroyed,  while  the 
intact  capsule  of  the  organ  still  furnishes  a  wall  of  protection  against  infec- 
tion for  the  surrounding  tissue.  A  single  tubercular  gland  is  seldom  larger 
than  a  walnut,  and  the  large  masses  found  in  the  neck  and  other  regions 
are  composed  of  several  glands  so  closely  packed  together  as  .to  give  the  ap- 
pearance of  a  single  gland.  When  the  capsule  becomes  infected,  the  same 
processes  are  initiated  here  as  in  the  parench5^ma  of  the  gland;  the  con- 
nective tissue  is  transformed  into  granulation-tissue,  which  undergoes  co- 
agulation-necrosis and  caseation  in  the  same  manner  as  the  fixed  tissue-cells 
of  the  parenchyma;  and,  finally,  after  perforation  of  the  capsule  has  taken 
place,  the  inflammation  extends  to  the  paraglandular  tissues,  resulting  in 
tubercular  periadenitis.  The  cheesy  material  may  dry  and  shrink  and  be- 
come inclosed  by  a  capsule  of  dense  connective  tissue,  resulting  in  calcifica- 
tion; or  it  undergoes  liquefaction.  If  secondary  infection  with  pus-microbes 
take  place, — a  not  infrequent  occurrence  in  tuberculosis  of  the  glands  of 
the  neck, — an  acute  suppurative  infiammation  takes  the  place  of  the  chronic 
process,  and  almost  without  exception  results  in  a  rapidly-spreading  sup- 
purative periadenitis.  The  connective  tissue  surrounding  the  gland  becomes 
swollen  and  oedematous  and  large  abscesses  form,  which,  on  being  incised, 
give  exit  to  pus  which  resembles  the  pus  of  an  ordinary  phlegmonous  in- 
flammation. The  suppurative  inflammation  results  in  extensive  detachment 
of  the  cheesy  glands,  which  at  this  time  can  be  readily  enucleated  by  the 
finger.  If,  however,  the  abscess  is  simply  incised,  and  the  radical  operation 
postponed  for  weeks  or  months,  the  removal  of  such  glands  is  an  exceedingly 


TUBEECULOSIS    OF    LYMPHATIC    GLANDS.  533 

difficult  task,  as  the  capsule  of  the  gland  will  then  be  found  intimately  ad- 
herent to  the  surrounding  tissues. 

Symptoms  and  Diagnosis. — Tuberculosis  of  the  lymphatic  glands  occurs 
most  frequently  in  persons  between  15  and  30  years  of  age.  The  regions 
most  frequently  affected  are  the  cervical,  parotid,  submaxillar^^,  axillary, 
and  inguinal.  Tuberculosis  of  the  parotid,  submaxillary,  and  ceryical  lym- 
phatic glands  is  often  preceded  by  eczema  of  the  scalp,  ears,  or  face,  or  by  a 
catarrhal  or  tubercular  inflammation  of  the  mucous  membrane  lining  the 
nose  and  pharjmx.  It  is  possible  that  in  many  of  these  cases  the  catarrhal 
inflammation  creates  the  necessary  infection-atrium  for  the  entrance  of  the 
^bacilli  into  the  lymphatic  channels;  or,  what  is  more  probable,  that  which 
has  been  regarded  as  a  catarrhal  inflammation  is,  in  reality,  a  mild  tubercular 
inflammation  that  may  disappear  after  infection  of  the  lymphatic  glands  has 
occurred.  In  the  region  of  the  neck,  the  first  glands  affected  are  usually 
the  submaxillary,  or  the  glands  just  behind,  in  front,  or  below  the  external 
meatus.  Progressive  infection  is  the  most  characteristic  clinical  feature  of 
tuberculosis  of  the  lymphatic  glands.  Eegional  infection,  as  has  been  stated, 
usually  takes  place  by  the  extension  of  the  disease  from  gland  to  gland,  until 
the  whole  chain  in  a  region  has  become  affected.  In  a  case  far  advanced,  for 
instance,  the  glands  first  affected  may  be  as  large  as  a  walnut;  their  size 
then  gradually  diminishes,  so  that  those  last  infected  may  not  be  larger  than 
a  split  pea.  The  degenerative  changes  are  also  most  marked  in  the  glands 
first  affected;  so  that,  while  the  primary  foci  show  well-marked  evidences  of 
caseation,  and  caseation  with  liquefaction,  the  glands  last  infected  still  pre- 
sent a  normal  pinkish  color.  The  number  of  glands  affected  in  one  region 
varies  from  one  to  twenty  or  more.  If  many  glands  are  affected,  the  hyper- 
plastic inflammation  in  their  periphery  usually  results  in  their  becoming 
matted  together  into  a  dense  nodular  mass.  With  the  exception  of  the  neck, 
it  is  seldom  that  more  than  one  anatomical  region  is  affected.  In  the  cervical 
region  it  is  not  uncommon  to  find  the  glands  on  both  sides  affected  at  the 
same  time.  The  infected  glands  increase  gradually  in  size;  they  are  painless 
and  not  tender  on  pressure.  At  first  they  are  movable,  and  appear  loosely 
attached  to  the  surroimding  tissues.  With  the  appearance  of  periadenitis 
the  swelling  rapidly  increases  in  size,  and  the  gland  becomes  fixed  and  im- 
movable. Liquefaction  of  the  cheesy  material  is  announced  by  softening 
and  perceptible  fluctuation.  Secondary  infection  with  pyogenic  microbes 
is  followed  by  phlegmonous  inflammation  in  the  capsules  and  in  the  con- 
nective tissue  surrounding  the  affected  glands.  The  course  of  the  disease, 
so  far  as  time  is  concerned,  is  extremely  variable.  The  extension  of  the  in- 
fection and  the  growth  of  the  swellings  may  become  arrested  for  months  or 
years,  when  the  disease  may  take  a  new  start  and  pursue  its  typical  course. 
I  recollect  the  case  of  a  woman,  45  years  of  age,  who  had  an  enlarged  gland 


534  PRINCIPLES    OF    SUEGERY. 

the  size  of  a  hazel-nut  in  the  upper  cervical  region,  which  remained  station- 
ary for  twenty  years,  when  the  swelling  rapidly  increased  in  size;  new  glands 
hecame  infected,  and,  when  the  glands  were  removed  by  operation,  it  was 
seen  that  the  first  gland  was  composed  of  a  thickened  capsule,  distended  to 
its  utmost  by  inspissated  cheesy  material.  The  capsule  showed  evidences  of 
recent  tubercular  inflammation,  and  small  foci  of  caseation  were  detected  in 
the  glands  that  had  recently  become  infected.  When  a  true  suppuration 
takes  place  in  a  tubercular  lymphatic  gland,  it  does  so  in  consequence  of  a 
secondary  infection  with  pyogenic  microorganisms.  A  spontaneous  and  per- 
manent cure  is  not  infrequently  effected  by  the  substitution  of  an  acute  sup- 
purative process  in  place  of  the  primary  specific  chronic  inflammation,  which 
destroys  the  entire  soil  of  the  bacillus  tuberculosis  and,  at  the  same  time, 
effects  complete  elimination  of  the  bacilli  through  the  discharge  of  the  ab- 
scess. While  tuberculosis  of  the  lymphatic  glands  often  stands  in  a  direct 
causative  relationship  to  and  precedes  general,  diffuse,  and  pulmonary  tuber- 
culosis, it  is  seldom  observed  as  a  secondary  affection  in  the  course  of  pulmo- 
nary tuberculosis.  I  have  observed  one  case  of  tuberculosis  of  the  lungs  with 
secondary  infection  of  the  Ij^mphatic  glands.  The  patient  was  a  woman,  50 
years  of  age,  who  had  suffered  for  two  years  from  well-marked  typical  tuber- 
culosis of  the  lungs,  when  the  glands  on  both  sides  of  the  neck  became  in- 
fected, and  continued  to  increase  in  number  and  in  size  until  she  died,  six 
months  later.  Frankel  reports  an  interesting  case  in  which  lymphatic  and 
pulmonary  tuberculosis  developed  almost  simultaneously.  The  patient  was 
a  woman,  51  years  of  age,  who  had  given  birth  to  two  children,  their  father 
being  the  subject  of  advanced  tuberculosis,  and  both  of  whom  died  of  tuber- 
culosis. She  had  been  in  perfect  health  until  her  49th  year,  when  she  was 
attacked  simultaneously  with  pulmonary  and  glandular  tuberculosis,  from 
the  combined  effects  of  which  she  died  in  a  few  months.  In  exceptional 
cases  glandular  tuberculosis  pursues  an  acute  course.  Delafield  reports  an 
exceedingly  interesting  case  of  this  kind.  The  disease  commenced  with  en- 
largement of  one  of  the  cervical  glands  near  the  angle  of  the  lower  jaw,  with 
a  temperature  of  40°  C.  (104°  F.),  and  rapid  extension  to  the  proximal  glands 
as  far  as  the  clavicle.  Symptoms  of  pulmonary  complication  were  not  pres- 
ent. Eapid  emaciation  and  marked  anaemia  supervened,  followed  after  six 
weeks  by  swelling  of  axillary  and  inguinal  glands.  Ophthalmic  examination 
revealed  the  same  conditions  of  retina  and  papilla  as  in  leukaemia  or  Bright's 
disease.  A  few  days  after  the  beginning  of  the  disease  profuse  diarrhoea 
and  reduction  to  nearly  normal  temperature  occurred.  The  diagnosis  was 
between  malignant  lymphoma  and  tubercular  adenitis.  During  the  further 
course  of  the  disease  bronchial  breathing  in  both  lungs  appeared.  Heart, 
liver,  and  spleen  appeared  to  be  normal.  Urine  normal,  but  increase  of  tem- 
perature and  respirations  took  place  during  this  time.     Death  occurred  in 


TUBERCULOSIS    OF    LYMPHATIC    GLANDS.  535 

less  than  five  months.  At  the  autopsy,  the  lungs  were  found  congested  and 
oedematous,  with  red  hepatization  of  the  lower  lobes  and  a  few  miliary  tuber- 
cles. The  spleen  contained  many  miliary  tubercles  the  size  of  the  head  of  a 
pin,  and  most  of  them  in  a  state  of  cheesy  degeneration.  The  mesenteric 
glands  were  much  enlarged,  and  a  few  of  them  in  a  condition  of  cheesy  de- 
generation and  calcification.  In  the  cheesy  matter  bacilli  were  found.  All 
the  cervical  glands  were  affected  with  softening  and  cheesy  degeneration 
in  the  centre.  The  calcification  of  mesenteric  glands  pointed  to  an  earlier 
afi^ection.  The  disease  remained  latent  and  recurred  in  the  same  glands,  and, 
later,  extended  to  the  cervical  glands.  This  case  resembles  the  cases  de- 
scribed by  Hilton-Fagge  and  Pye-Smith. 

In  reference  to  the  dissemination  in  cases  of  acute  miliary  tuberculosis, 
Weigert  has  pointed  out  that  in  some  cases  the  bacilli  are  conveyed  through 
the  lymphatic  system  successively  until  they  reach  the  general  circulation, 
while  in  others,  and  by  far  the  greater  number,  generalization  of  the  tuber- 
cular process  takes  place  more  directly  by  the  entrance  of  tubercular  prod- 
ucts through  a  vein, — an  occurrence  which  is  followed  at  once  by  rapid  and 
extensive  diffusion  by  embolic  processes;  when  the  bacilli  have  reached  the 
systemic  circulation,  the  intensity  of  symptoms  and  subsequent  course  of 
the  disease  depend  on  the  number  of  bacilli  which  the  blood  contains.  As 
regards  the  frequency  of  secondary  infection  of  the  lungs  in  cases  of  gland- 
ular tuberculosis,  Frankel  found  it  present  in  only  18  out  of  148  cases.  In 
making  a  differential  diagnosis  it  becomes  necessary  to  distinguish  tubercular 
adenitis  from  simple  adenitis,  suppurative  adenitis,  syphilitic  adenitis,  car- 
cinoma, lymphoma,  lymphosarcoma,  and  pseudoleukemia. 

Simple  adenitis  is  the  result  of  the  entrance  into  the  lymphatic  circula- 
of  noxse  that  neither  produce  suppuration  nor  the  formation  of  new  tissue. 
A  number  of  glands  corresponding  to  the  direction  of  the  lymph-current 
from  the  infection-atrium,  through  which  the  irritant  gained  entrance,  en- 
large, but  the  inflammatory  swelling  subsides  shortly  after  the  cessation  of 
the  primary  cause,  with  perfect  restoration  of  the  structure  and  function  of 
the  affected  glands.  Suppurative  adenitis  is  an  acute  affection  which  ter- 
minates in  the  formation  of  pus  in  a  few  days.  Syphilitic  adenitis  devel- 
oping in  the  course  of  a  primary  syphilitic  sore  only  attacks  the  glands  con- 
taminated with  lymph  coming  from  the  infected  area.  The  adenitis  which 
accompanies  secondary  and  tertiary  syphilis  is  not  limited  to  a  single  region; 
nearly  all  of  the  external  lymphatic  glands  are  more  or  less  enlarged,  but 
especially  those  in  the  occipital  and  cubital  regions.  Carcinoma  never  occurs 
as  a  primary  lesion  in  the  lymphatic  glands,  and  when  regional  infection  has 
occurred  it  is  not  difficult  to  locate  the  primary  tumor.  Lymphoma  is  a  be- 
nign tumor  of  the  lymphatic  glands,  and  as  such  is  always  met  with  as  a 
single  tumor.    Lymphosarcoma  represents  the  primary  malignant  tumor  of 


536  PKINCIPLES    OF    SUEGERY. 

the  lymphatic  glands,  and  gives  rise  to  regional  and  general  infection,  the 
infection  in  these  respects  resembling  the  clinical  tendencies  of  tubercular 
adenitis.  Lymphosarcoma,  however,  is  a  tumor,  not  an  inflammatory  swell- 
ing, and,  consequently,  the  tissues  of  which  it  is  composed  do  not  undergo 
degeneration  and  necrosis  at  such  an  early  stage,  and  the  rapid  tissue-in- 
crease leads  to  the  formation  of  large  tumors,  while  tubercular  glands  the 
size  of  an  almond  contain  cheesy  material.  The  unlimited  growth  which 
characterizes  sarcoma  is  checked  in  the  tubercular  glands  by  necrosis  of  the 
cells  which  compose  the  swelling.  In  pseudoleukasmia  the  fixed  tissue-cells 
of  the  parenchyma  of  the  glands  proliferate  by  being  acted  upon  by  a  mi- 
crobe as  yet  unknown;  but  this  microbe,  unlike  the  bacillus  of  tuberculosis, 
is  diffused  more  extensively  through  the  lymphatic  system,  involving  one 
region  after  another  until,  after  the  disease  has  been  once  well  developed, 
almost  every  lymphatic  gland  in  the  body  has  become  infected.  The  sup- 
posed microbe  of  pseudoleukEemia  possesses  the  property  of  producing  new 
tissue  by  its  action  upon  the  fixed  cells.,  but  the  new  product  does  not  un- 
dergo caseation.  As  the  last  and  infallible  diagnostic  measures,  must  be 
mentioned  the  search  for  the  bacillus  of  tuberculosis  by  the  use  of  the  micro- 
scope and  inoculation  experiments. 

Prognosis.  —  A  tubercular  lymphatic  gland  is  always  a  source  of 
danger.  Even  if  the  disease  becomes  latent,  a  recurrence  may  take  place 
at  any  time,  and  lead  to  rapid  regional  and  general  infection,  or  general 
infection  may  take  place  directly  from  an  old  cheesy  focus  by  the  en- 
trance of  bacilli  or  their  spores  into  a  vein.  The  prognosis  is  very  grave 
if  the  patient  is  anaemic  and  the  glands  on  both  sides  of  the  neck  are 
affected  at  the  same  time.  Frankel  estimates  the  average  duration  of  the 
disease  from  three  to  four  years.  In  the  cases  which  he  collected  the 
shortest  time  was  two  months  and  the  longest  thirty  years.  Sooner  or 
later,  pulmonary  or  diffuse  general  tuberculosis  is  almost  sure  to  take 
place.  A  spontaneous  cure  is  possible  if  secondary  infection  occur  in  cases 
where  only  a  few  of  the  glands  have  become  infected,  and  suppuration 
results  in  the  elimination  of  all  the  infected  tissue.  Suppuration  only 
hastens  a  fatal  termination  if  many  glands  are  affected. 

Treatment. — As  primary  lymphatic  tuberculosis,  in  most  instances, 
signifies  the  entrance  of  bacilli  through  a  loss  of  continuity  of  the  skin 
or  a  mucous  membrane,  or  through  the  socket  of  a  carious  tooth,  locali- 
zation occurring  in  one  of  the  nearest  glands  to  the  portio  invasionis,  it 
must  be  regarded  primarily  as  a  local  process  amenable  to  timely  surgical 
treatment.  The  capsule  of  the  lymphatic  glands  constitutes  a  very  effi- 
cient barrier  against  infection  of  the  paraglandular  tissue  for  a  long  time, 
and  perforation  of  the  capsule  can  only  take  place  after  the  disease  has 
made  considerable  progress,  and  has  been  followed  by  extensive  caseation 


TUBEKCULOSIS    OF    LYMPHATIC    GLANDS.  537 

and  especially  by  suppuration.  Early  operative  interference  is  as  necessary 
■in  the  treatment  of  tubercular  adenitis  as  in  the  treatment  of  malignant 
tumors,  and  holds  out  more  encouragement,  so  far  as  a  permanent  cure  is  con- 
cerned. By  a  thorough  removal  of  the  jjrimary  foci  of  infection,  successive 
infection  of  proximal  glands  and  general  miliary  tuberculosis  are  pre- 
vented almost  to  a  certainty  if  the  operation  is  performed  before  the 
disease  has  extended  beyond  the  capsule  of  the  glands.  If  the  operation 
is  done  at  such  a  favorable  time  it  is  not  attended  by  any  great  difficulties, 
as  the  glands  can  be  readily  excised,  and,  as  suppuration  has  not  taken 
place,  the  wound  usually  heals  by  primary  intention.  If,  however,  the 
tubercular  inflammation  has  involved  many  glands,  and  has  extended  to 
the  connective  tissue  surrounding  them,  the  operation  becomes  one  of  the 
most  formidable  in  surgery,  on  account  of  the  close  proximity  of  impor- 
tant vessels  that  are  often  imbedded  in  the  mass.  Under  such  circum- 
stances complete  removal  is  frequently  impossible  and  early  local  recidiva- 
tion  is  inevitable,  owing  to  imperfect  removal  of  the  primary  microbic 
cause.  Traumatic  dissemination  is  very  likely  to  follow  all  imperfect  opera- 
tions in  which  portions  of  glands  or  infected  capsules  are  left  behind,  as  the 
operation  wounds  are  inoculated  with  bacilli  liberated  during  the  operation. 
I  have  seen  a  number  of  such  cases,  as  early  as  a  week  after  the  operation, 
the  entire  surface  of  the  wound  covered  by  a  thick  layer  of  granulation- 
tissue,  which  showed  all  the  histological  evidences  and  possessed  all  the 
bacteriological  properties  of  tubercular  tissue.  As  a  testimony  in  favor  of 
the  operative  treatment  of  tubercular  adenitis,  I  will  quote  from  the  paper 
of  Schuell,  who  collected  56  cases  of  tuberculosis  of  the  cervical  glands 
that  were  treated  by  extirpation  in  the  clinic  at  Bonn.  In  37  of  these 
cases  he  was  able  to  learn  the  ultimate  result.  In  57  per  cent,  the  opera- 
tion was  followed  by  complete  recovery,  in  37  per  cent,  the  disease  re- 
turned at  the  site  of  operation,  and  in  4  cases  death  resulted  from  pul- 
monary tuberculosis.  The  largest  number  of  cases  were  patients  between 
10  and  20  years  of  age. 

Frankel  reports  128  cases  operated  upon  by  Billroth,  some  of  the 
operations  being  quite  serious;  in  16  cases  the  internal  jugular  vein  had 
to  be  tied.  In  91  of  the  operations  the  wound  healed  by  primary  union, 
and  in  25  the  healing  was  retarded  by  suppuration.  Erysipelas  compli- 
cated the  result  five  times.  In  one  of  these  cases  a  large  part  of  the  tuber- 
cular mass  was  left,  and  it  was  noticed  that  the  erysipelas  had  no  effect 
on  the  tubercular  process.  Only  in  49  of  the  cases  operated  on  could  the 
final  result  be  obtained.  Taking  three  and  a  half  years  as  the  time  when 
the  patient  could  be  considered  exempt  from  a  recurrence  of  the  disease, 
it  was  ascertained  that  in  24  per  cent,  no  relapse  followed  the  operation, 
a  local  relapse  was  observed  in  14  per  cent.,  and  reappearance  of  the  dis- 


538  PEINCIPLES    OF    SUEGERY. 

ease  distant  from  the  seat  of  operation  in  4  per  cent.  The  results  of 
operation  for  tuberculosis  of  the  lymphatic  glands  have  shown  the  neces- 
sity of  early  operating,  as  delay  renders  the  operation  more  difficult,  on 
account  of  the  progressive  regional  dissemination  of  the  disease  and  the 
occurrence  of  pathological  changes  within  and  around  the  affected  glands, 
which  render  their  complete  removal  more  difficult;  while  at  the  same 
time  the  danger  of  general  infection  increases  with  the  local  extension  of 
the  disease.  If  the  glands  have  suppurated,  or  if  the  capsule  has  become 
perforated  and  tubercular  periadenitis  or  suppurative  periadenitis  has 
taken  place,  and  many  glands  are  simultaneously  affected,  it  may  not  be 
advisable  to  resort  to  excision,  as  when  extensive  connective-tissue  infil- 
tration is  present  it  would  be  almost  impossible  to  remove  all  of  the  in- 
fected tissues. 

In  such  cases  free  incisions  should  be  made,  and  the  tubercular 
product  be  removed  with  a  Volkmann  spoon.  The  proximal  glands  which 
have  not  undergone  such  extensive  secondary  pathological  changes  can  be 
excised.  The  scraped  surface  is  freely  iodoformized  and  the  wounds  are 
sutured  and  drained.  In  removing  the  glands  of  the  neck  it  is  always  im- 
portant to  expose  the  infected  area  by  a  large  incision.  The  operator 
should  not  only  feel,  hut  see,  every  gland  he  removes.  Accidents  are  more 
liable  to  happen  by  removing  the  glands  through  a  small  than  a  large  in- 
cision. As  in  cases  of  secondary  carcinoma  of  the  lymphatic  glands  the 
extent  of  the  disease  is  only  ascertained  after  incision,  so  in  glandular 
tuberculosis  the  extent  of  the  area  of  infection  can  only  be  determined 
after  the  external  incision  is  made.  Whole  chains  of  small  glands  which 
could  not  be  felt  through  the  skin  are  then  exposed.  In  tuberculosis  of 
the  glands  of  the  neck  the  region  between  the  mastoid  process  and  the 
angle  of  the  lower  Jaw  is  almost  always  the  primar}^  seat  of  infection. 
From  here  either  the  chain  of  glands  behind  the  sterno-cleido-mastoid 
muscle  or  the  deep  glands  which  follow  the  sheath  of  the  large  vessels  of 
the  neck  are  affected,  or  the  superficial  and  deep  lymphatics  are  affected 
simultaneously.  It  has  been  my  custom  to  expose  the  glands  occupying 
the  upper  region  of  the  neck  by  a  transverse  incision,  extending  from  the 
tip  of  the  mastoid  process  of  the  temporal  bone  to  the  lower  angle  of  the 
jaw,  and  from  there  along  the  lower  border  of  the  bone,  as  far  as  the  dis- 
ease extends  in  the  submaxillary  region.  This  incision  is  joined  by  an- 
other, extending  from  the  angle  of  the  lower  jaw  either  along  the  anterior 
border  of  the  sterno-cleido-mastoid  muscle  as  far  as  its  sternal  insertion, 
if  the  deep  glands  are  to  be  removed,  or,  if  the  posterior  superficial  set  of 
glands  are  affected,  it  is  carried  in  a  downward  and  backward  direction, 
following  the  chain  of  enlarged  glands.  If  the  latter  incision  is  selected, 
the  external  jugular  vein  is  divided  between  two  ligatures.    The  platysma 


TUBERCULOSIS    OF    LYMPHATIC    GLANDS.  539 

myoides  muscle  is  divided  throughout  the  whole  length  of  the  incision 
before  an  attempt  is  made  to  remove  any  of  the  glands.  The  surgeon 
should  aim  to  remove,  as  nearly  as  he  can,  all  of  the  infected  glands  in  one 
continuous  string.  In  many  cases  one  or  two  tubercular  glands  will  be 
found  imbedded  in  the  lower  portion  of  the  parotid  gland,  and  very  fre- 
quently also  in  the  submaxillary  salivary  gland.  If  the  tubercular  glands^ 
with  their  capsules,  can  be  enucleated,  this  should  be  done;  but  if  this 
is  impossible,  it  is  better  to  remove  the  lower  portion  of  the  parotid  with 
them  in  preference  to  leaving  any  infected  tissue  behind.  Under  the  same 
circumstances  I  prefer  to  extirpate  the  submaxillary  gland  in  toto.  If  the 
deep  glands  of  the  neck  must  be  removed,  it  is  absolutely  necessary  to 
divide  the  sterno-cleido-mastoid  muscle  near  its  centre,  and  then  reflect 
both  ends  nearly  as  far  as  the  origin  and  insertion  of  the  muscle,  which 
freely  exposes  not  only  the  affected  glands,  but  also  the  important  struct- 
ures of  the  neck,  which  it  is  important  to  avoid  in  the  dissection.  The 
dissection  must  always  be  made  with  the  greatest  care,  and  in  the  vicinity 
of  the  large  vessels  every  structure  must  be  identified  before  it  is  sepa- 
rated. The  finger  and  blunt-pointed,  curved  scissors  are  the  most  impor- 
tant instruments  in  making  the  deep  dissection.  The  internal  jugular 
vein  should  be  exposed  before  any  of  the  deep  glands  are  removed,  for  if  this 
structure  is  seen  it  can  be  carefully  followed  the  whole  length  of  the  neck 
without  wounding  it  unintentionally.  If  the  internal  jugular  vein  is  im- 
bedded among  the  enlarged  glands,  and  cannot  be  isolated  without  great 
danger  of  injuring  it,  it  is  better  to  resect  it  between  two  ligatures  than  to 
run  the  risk  of  wounding  it  accidentally.  The  chain  of  enlarged  glands  is 
followed  as  far  as  possible,  as  it  is  much  better  to  remove  a  few  healthy 
lymphatic  glands  than  to  leave  minute,  almost  invisible  foci  of  the  dis- 
ease. After  all  the  infected  glands  have  been  removed  the  continuity  of 
the  divided  muscle  is  restored  by  suturing.  At  least  six  catgut  sutures 
are  necessary  to  join  the  ends  accurately.  I  have  usually  succeeded  in 
removing  all  the  glands  after  division  of  this  muscle  without  dividing  the 
spinal  accessory  nerve,  but,  should  this  be  necessary,  the  divided  ends 
are  joined  by  suturing  before  the  muscle  is  united.  Drainage  in  the  sub- 
maxillary region  and  at  the  most  dependent  point  of  the  wound  in  the 
neck  must  always  be  established.  The  platysma  muscle  should  be  united 
with  buried  sutures  before  the  skin  is  sutured.  I  have  recently,  except 
in  cases  of  very  limited  tuberculosis  of  the  cervical  glands,  abandoned 
the  straight  incision,  which  is  followed  so  often  by  a  disfiguring  scar,  and 
have  substituted  for  it  an  incision  which  resembles  the  shape  of  the  letter 
S,  as  here  illustrated.  This  incision  affords  free  access  to  the  deep  tissues 
of  the  neck  and  the  entire  chain  or  chains  of  tubercular  glands,  and  the 
resulting  scar  never  appears  in  the  form  of  an  elevated,  disfiguring  ridge. 


540  PRINCIPLES    OF    SUEGERY. 

Wounds  of  the  neck,  on  account  of  the  irregular  outlines  of  the  neck, 
shoulder,  and  chest,  require  a  very  copious  antiseptic  dressing  to  effectually 
exclude  the  entrance  of  pathogenic  microorganisms  after  the  operation. 
The  dressing  should  he  kept  in  place  by  a  few  turns  of  the  plaster-of-Paris 
bandage,  which  also  keeps  the  head  in  proper  position  during  the  time 
required  in  the  healing  of  the  large  wound.  The  sutured  muscle  must  be 
kept  in  a  relaxed  position  until  firm  union  has  taken  place  between  the 
sutured  ends,  which  usually  requires  from  two  to  three  weeks.  On  the 
second  or  third  day  the  dressing  is  changed,  the  drains  are  removed,  and, 
if  the  wound  has  remained  aseptic,  the  second  dressing  can  be  allowed  to 
remain  for  ten  days  or  two  weeks,  when  it  is  changed,  and  the  superficial 
stitches  are  removed.  If  all  of  the  diseased  tissues  have  been  removed, 
and  the  wound  has  remained  aseptic,  the  healing  process  will  be  found 
nearly  completed  at  this  time. 


Fig.  182. — S-shaped  Incision  in  the  Operation  for  the  Removal  of  Tubercular 
Glands  of -the  Neck. 

Local  reciirrence  of  the  disease  should  only  stimulate  the  surgeon 
to  continue  the  active  warfare,  and  glands  are  removed  as  soon  as  they 
can  be  felt.  I  have  repeatedly  performed,  on  the  same  patients,  three  and 
four  operations  in  as  many  years,  and  had  the  satisfaction  of  finally  eradi- 
cating the  disease  completely.  In  one  case  I  performed  21  ojoerations  during 
the  course  of  five  years  with  ultimate  complete  success.  Parenchymatous  in- 
jections of  carbolic  acid,  so  strongly  recommended  by  Hueter  in  the  treat- 
ment of  tubercular  glands,  have  little  or  no  effect  in  either  arresting  further 
development  of  the  disease  in  the  affected  glands  or  in  jDreventing  further 
regional  infection.  I  have  seen,  in  cases  treated  by  this  method,  glands 
finally  destroyed  by  suppuration  caused  by  the  punctures;  but  the  bacilli 
remained  in  the  cicatricial  tissue,  as  was  evident  by  the  cedematous,  congested 
scar,  and  from  here  additional  glands  became  infected. 


TUBERCULOSIS    OF    PEEITONEUM.  541 

Genzmer  advised  ignipuncture  in  the  treatment  of  tubercnlar  glands^ 
and  claims  for  this  method  excellent  results.  This  treatment  is  applicable 
only  in  cases  where  a  few  of  the  more  superficial  glands  are  affected,  and 
where  patients  positively  refuse  to  submit  to  a  more  radical  procedure. 
It  is  absolutely  contraindicated  when  many  glands  are  affected,  as  in  cases 
where  the  glands  are  affected  they  have  undergone  extensive  secondary 
pathological  changes.  The  general  treatment  of  tuberculosis  of  the 
lymphatic  glands  is  the  same  as  in  the  other  forms  of  local  tuberculosis. 
I  have  seen  the  best  effects  from  the  administration  of  guaiacol,  arsenic, 
and  iron,  followed  or  alternated  by  codliver-oil.  All  external  applications 
to  bring  about  resolution  are  worse  than  useless. 

TUBEECULOSIS   OF   PERITONEUM. 

Tubercular  peritonitis  occurs  as  one  of  the  lesions  of  acute  general 
tuberculosis,  with  chronic  pulmonary  phthisis,  with  tubercular  inflamma- 
tion of  the  genito-urinary  tract,  and  as  a  local  inflammation.  As  a  sur- 
gical lesion  only  the  local  form  will  be  considered  here. 

Bacteriological  Remarks.- — The  susceptibility  of  the  peritoneum  to 
tubercular  infection  has  been  well  established  by  numerous  inoculation 
experiments.  The  peritoneum  can,  under  favorable  conditions,  dispose 
of  a  large  dose  of  a  pure  culture  of  pus-microbes,  but  the  implantation 
of  a  minute  fragment  of  tubercular  tissue  in  animals  susceptible  to  tuber- 
culosis is  almost  certain  to  be  followed  by  genuine  local  and  general  tuber- 
culosis. For  the  surgeon,  only  those  forms  of  peritoneal  tuberculosis  have 
interest  which  are  either  caused  by  an  extension  of  an  adjacent  tubercular 
process  to  the  peritoneum  or  from  primary  localization  of  the  bacillus 
within  or  upon  this  membrane.  The  prevalence  of  the  affection  in  the 
female  sex,  among  the  cases  which  have  been  reported,  points  to  the 
Fallopian  tubes  as  a  frequent  primary  seat  of  infection,  with  secondary 
invasion  of  the  peritoneum  from  this  source.  Although  the  genital  organs 
in  the  male  are  more  frequently  the  seat  of  tuberculosis  than  in  the 
female,  so  far  only  a  few  cases  of  peritoneal  tuberculosis  in  males  have 
been  reported:  by  Kllmmell,  Lindfors,  and  others.  Eecent  clinical  and 
post-mortem  observations"  have  shown  that  in  not  an  inconsiderable  num- 
ber of  cases  peritoneal  tuberculosis  is  secondary  to  intestinal  tuberculosis. 
The  peritoneal  complication  may  set  in  during  the  active  stage  of  in- 
testinal tuberculosis  or  long  after  the  intestinal  lesions  have  healed. 
Tuberculosis  of  the  peritoneum,  by  extension  from  a  tubercular  focus  in 
the  genital  organ,  can  only  mean  an  infection  by  contact:  the  bacillus  of 
tuberculosis  transferred  from  the  primary  seat  of  infection,  and  localiza- 
tion by  implantation  upon  the  peritoneal  surface.  Implantation  experi- 
ments in  animals  furnish  a  good  illustration  of  the  manner  in  which  the 


543  PRINCIPLES    OF    SUEGERY. 

process  becomes  diffuse.  At  the  point  of  implantation  a  granulation-mass 
forms  around  the  graft,  and  from  here  innumerable  tubercle-nodules  take 
their  starting-point,  forming  everywhere  new  centres  of  infection.  The 
movements  of  the  abdominal  walls  during  respiration  and  the  peristaltic 
action  of  the  intestines  are  potent  factors  concerned  in  the  local  dissemi- 
nation of  the  tubercular  infection.  Anatomically,  the  peritoneum  is  so 
closely  allied  to  the  lymphatic  glands  that  we  have  every  reason  to  believe 
that  primary  tuberculosis  can  occur  in  this  structure  as  well  as  in  the 
lymphatic  glands.  In  primary  tuberculosis  of  the  peritoneum  infection 
takes  place  in  the  same  manner  as  in  intact  joints,  by  floating  bacilli  be- 
coming arrested  in  the  capillary  vessels  of  the  membrane,  where  the 
primary  nodule  forms,  from  which,  again,  as  from  a  graft,  local  dissemi- 
nation takes  place.  These  cases  are,  in  the  true  sense  of  the  word,  not 
cases  of  primary  tuberculosis,  as  the  peritoneal  affection  is  only  a  local 
expression  of  an  antecedent  infection.  As  the  peritoneum  is  endowed 
with  absorptive  capacities  of  a  high  degree  and  is  in  direct  communication 
with  the  lymphatic  system,  we  would  naturally  expect  that  tuberculosis 
of  this  structure  would  lead  to  early  general  dissemination.  But  in  peri- 
toneal tuberculosis  we  observe  the  same  tendency  to  limitation  of  the  in- 
fective process  as  in  joints,  by  the  formation  of  an  impenetrable  wall  of 
connective  tissue,  which  imparts  so  often  to  this  form  of  peritonitis  its 
circumscribed  character. 

Clinical  Studies. — Ktimmell  looks  upon  peritoneal  tuberculosis  as  a 
purely  local  affection,  amenable  to  surgical  treatment  in  the  same  sense 
and  to  the  same  extent  as  tuberculosis  of  a  joint.  That  some  of  these  cases 
can  be  permanently  cured  by  local  treatment  is  well  shown  by  a  case  treated 
by  Sir  Spencer  Wells  twenty-six  years  ago  by  abdominal  section,  the  pa- 
tient having  remained,  up  to  the  time  the  report  was  made,  in  perfect 
health.  In  a  paper  on  this  subject  Fehling  reports  4  cases  of  his  own, 
and  gives  an  account  of  all  the  operations  which  had  been  done  up  to 
that  time:  21  in  number.  Of  this  number,  15  recovered,  and  the  patients 
are  known  to  have  been  well  from  one  year  to  twenty-three  years,  and 
in  a  number  of  cases  their  condition  was  learned  four  to  five  years  after 
the  operation.  Six  of  the  patients  died:  2  of  sepsis,  1  of  pyaemia  several 
months  after  the  operation,  and  3  from  the  continuance  of  the  disease  for 
which  the  operation  was  performed.  In  5  of  the  cases  ascites  attended 
the  tuberculosis;  in  3  the  swelling  was  not  due  to  effusion,  but  to  ad- 
hesions between  intestinal  loops  that  were  covered  with  miliary  tubercles. 

Of  54  cases  of  laparotomy  for  peritoneal  tuberculosis,  collected  by 
Trzebicky,  4  died  from  the  immediate  consequences  of  the  operation, 
while  in  a  fifth  death  occurred  after  the  operation  from  acute  miliary 
tuberculosis,  though  the  fl^iid  had  not  reaccumulated.     One  case  died  in 


TUBEECULOSIS    OF    PEEITONEUM.  543 

four  months  from  general  tuberculosis  without  the  peritonitis  disappear- 
ing; cures  resulted  in  40  cases,  though  here  and  there  evidence  of  pul- 
monary tuberculosis  was  reported.  The  majority  of  cases  were  females, 
which  may  find  its  explanation  in  the  fact  that  most  were  operated  upon 
under  error  in  the  diagnosis  of  ovarian  cyst.  One  of  the  more  recent 
and  comprehensive  works  on  tuberculosis  of  the  peritoneum,  which  has 
appeared  from  the  pen  of  Vierordt  ("Ueber  die  Tuberculose  der  serosen 
Haute,"  in  Zeitsclirift  f.  Min.  Meclicin,  Bd.  xiii.  Heft  2),  should  be  con- 
sulted by  those  who  wish  to  secure  for  reference  an  exhaustive  treatise 
on  this  subject.  The  statistics  are  yet  too  meagre,  the  correctness  of  diag- 
nosis not  entirely  above  doubt,  and  the  period  of  observation  after  opera- 
tion not  long  enough;  but,  in  view  of  the  results,  there  is  no  longer  any 


Fig.  183.— Tubercular  Peritonitis  (Parietal  Peritoneum).  The  inflammatory  process 
is  accompanied  by  marked  connective-tissue  hyperplasia.  A,  connective-tissue  hyper- 
plasia; B,  blood-vessels;  O,  caseated  area;  D,  giant  cell;  E,  small  round-cell  infiltra- 
tion.    (Eosin  and  hsematoxylin  stain.) 

justification  for  expectant  treatment.  Even  though  in  some  cases  re- 
covery was  not  permanent,  the  fluid  did  not  reaccumulate,  and  the  pa- 
tients were  relieved  of  their  distress.  Spontaneous  recovery  from  tuber- 
cular peritonitis  is  exceptional,  and  operative  interference  is  indicated 
the  more,  as  it  would  seem  that,  in  many  cases,  tuberculosis  of  the  peri- 
toneum is  a  primary  affection  and  the  source  of  general  infection.  As  all 
other  therapeutic  measures  are  of  no  permanent  value  in  such  cases,  and 
laparotomy  done  under  aseptic  precautions  may  be  considered  almost  free 
from  danger,  the  operation  is  certainly  strongly  indicated. 

Pathology  and  Morbid  Anatomy. — The  effect  of  the  bacillus  of  tuber- 
culosis on  the  peritoneum  is  not  uniform,  and  the  conditions  found  in 
peritoneal  tuberculosis  are  variable.     Lindfors,  in  a  clinical  and  patho- 


544  PRINCIPLES    OF    SURGERY. 

logical  study,  based  on  109  recorded  cases  of  peritoneal  tuberculosis, 
divides  the  cases  into  seven  classes.  He  states  that  the  acute  variety  may 
assume  the  form  of  circumscribed,  general,  or  suppurative  peritonitis; 
in  the  chronic  form  there  may  be  a  free  or  encysted  effusion,  there  may 
be  simple  adhesions,  or  the  intestines  may  be  so  adherent  as  to  cause  intes- 
tinal obstruction.  Hyperplasia  of  the  connective  tissue  is  one  of  the  con- 
spicuous pathological  features  of  peritoneal  tuberculosis.  Two  distinct 
pathological  forms  are  met  with  clinically:  iibrinoplastic  and  hydropic.  The 
former  variety  is  characterized  by  copious  fibrinous  exudates,  diff'use,  firm 
adhesions;  the  latter  by  diffuse  miliary  tubercles  and  localized  or  diffuse 
ascites.  Lindf  ois  thinks  that  the  presence  of  acute  or  chronic  pleurisy  has  an 
important  bearing  on  the  diagnosis  of  tubercular  peritonitis.  He  is  strongly 
in  favor  of  laparotomy  and  the  free  use  of  iodoform  within  the  peritoneal 
cavity.  The  conditions  found  in  local  tubercular  peritonitis,  in  cases  sub- 
jected to  operative  treatment  and  in  examinations  made  in  the  post- 
mortem rooms,  are  such  that  all  cases  of  this  kind  can  be  conveniently 
classified  in  three  principal  groups  upon  a  pathological  basis: — 

1.  Tubercular  Ascites. — The  peritoneum  is  thickened,  hypergemic,  and 
studded  with  masses  of  tubercle-tissue  in  the  form  of  miliary  nodules. 
The  omentum  is  usually  similarly  affected.  If  the  effusion  is  general, 
occupying  the  whole  peritoneal  cavity,  the  adhesions  are  few  and  slight. 
If  the  fluid  is  encapsulated,  the  walls  of  the  cavity  are  formed  by  intestinal 
loops,  which  are  adherent  among  themselves  and  to  the  surrounding 
structures.  The  circumscribed  form  usually  takes  its  origin  from  the 
floor  of  the  pelvis,  and  often  gives  rise  to  a  swelling  which  simulates  an 
ovarian  cyst  to  perfection.  The  fluid  contained  in  the  peritoneal  cavity 
in  the  diffuse  form,  and  in  the  conflned  space  in  the  circumscribed  variety, 
is  either  a  clear,  transparent  serum,  or  serum  in  which  small  flocculi  are 
suspended,  or  it  has  become  slightly  turbid  from  the  admixture  of  the 
products  of  retrograde  tissue-metamorphosis.  The  visceral  peritoneum  of 
the  organs  exposed  to  infection  is  in  the  same  condition  as  the  parietal  peri- 
toneum. Coagulation-necrosis  and  caseation  of  the  nodules  appear  to  be 
retarded  for  a  much  longer  time  than  in  cases  of  glandular  tuberculosis.  The 
amount  of  fluid  may  vary  from  a  teacupful  in  the  circumscribed  to  4  or  6 
gallons  in  diffuse  tubercular  ascites.  Secondary  infection  is  found  most  fre- 
quently in  the  spleen,  pleurse,  and  lymphatic  glands. 

2.  Fibrinoplastic  Peritonitis. — In  this  form  of  tubercular  peritonitis 
no  fluid  is  found  in  the  peritoneal  cavity.  The  bacillus  of  tuberculosis 
produces  a  copious  inflammatory  product,  and  the  peritoneal  surfaces, 
which  are  studded  with  miliary  tubercles,  are  covered  by  a  thick  layer 
of  gelatinous  fibrin,  which  cements  together  all  the  adjacent  serous  sur- 
faces, so  that  the  whole  abdominal  cavity  appears  to  be  filled  with  a  large, 


TUBEECTJLOSIS    OF    PEEITONEUM.  545 

boggy  mass,  composed  of  all  the  viscera  adherent  to  each  other,  and  with 
the  interspaces  between  them  filled  with  fibrin.  The  inflammatory  product 
in  these  cases  is  rich  in  fibrin-producing  substances,  while  the  liquid 
transudation  is  either  scanty  or  is  absorbed  as  soon  as  it  is  poured  out. 

3.  Adhesive  Peritonitis. — In  this  variety  of  tubercular  peritonitis  the 
bacillus  of  tuberculosis  exerts  its  pathogenic  properties  more  on  the  fixed 
tissue-cells  than  the  blood-vessels.  The  primary  inflammatory  exudation 
is  slight,  but  the  endothelial  cells  proliferate  new  tissue,  which  undergoes 
cicatrization,  giving  rise  to  firm  and  extensive  adhesions.  The  plastic 
peritonitis  may  be  so  extensive  as  to  cause  intestinal  obstruction  from 
perfect  immobilization  of  a  large  portion  of  the  intestinal  tract.  In  this, 
as  well  as  in  the  foregoing  form  of  tubercular  peritonitis,  ulceration  of 
the  intestine  may  take  place,  resulting  in  the  formation  of  a  bimucous, 
internal  fistula  if  the  oiDcnings  in  two  adjacent  loops  correspond,  or  the 
formation  of  a  facal  abscess  with  a  subsequent  fgecal  fistula. 

Symptoms  and  Diagnosis. — As  tubercular  peritonitis  without  effusion 
is  not  amenable  to  successful  surgical  treatment  by  laparotomy,  nothing 
will  be  mentioned  in  reference  to  the  diagnosis  and  treatment  of  the 
fibrinoplastic  and  adhesive  varieties.  Tubercular  ascites  is  a  chronic  affec- 
tion, especially  when  it  occurs  in  the  circumscribed  form.  Pain  and  ten- 
derness are  not  prominent  or  even  constant  symptoms.  The  general 
health  is  at  first  but  little  impaired.  Fever  is  slight  or  entirely  absent. 
If  the  effusion  is  general,  it  comes  on  slowly,  almost  insidiously,  as  in 
ascites  from  other  causes.  From  the  absence  of  adhesions  the  fluid 
changes  its  location  according  to  the  position  of  the  patient.  If  the  pa- 
tient is  placed  in  the  dorsal,  recumbent  position,  the  lumbar  regions  are 
dull  on  percussion;  if  placed  on  the  side  the  upper  lumbar  region  is  tym- 
panitic, while  the  area  of  dullness  on  the  opposite  side  is  increased.  In 
circumscribed  tubercular  peritonitis  with  encapsulation  of  the  fluid,  the 
swelling  appears  first  either  in  the  hypogastric  or  one  of  the  iliac  regions. 
The  area  of  dullness  does  not  change  by  placing  the  patient  in  different 
positions.  In  free  ascites  tuberculosis  of  the  peritoneum  should  be  sus- 
pected, if  the  ordinary  causes  of  ascites,  cirrhosis  of  the  liver,  valvular 
disease  of  the  heart,  and  the  presence  of  an  intraabdominal  malignant 
tumor  can  be  excluded.  Circumscribed  tubercular  ascites  might  be  mis- 
taken for  ovarian  cyst,  pregnancy,  pyosalpinx  or  hydrosalpinx,  pyonephro- 
sis or  hydronephrosis,  cyst  of  pancreas,  enlarged  gall-bladder,  and  pelvic 
abscess.  Fluctuation  is  a  symptom  common  to  all  of  these  conditions,  and 
a  differential  diagnosis  can  only  be  made  by  a  careful  study  of  the  clinical 
history  and  by  a  thorough  examination.  Pregnancy  can  usually  be  ex- 
cluded by  ascertaining  the  size  of  the  uterus  and  by  the  presence  or  ab- 
sence of  the  usual  signs  of  gestation.     A  pyosalpinx  or  hydrosalpinx  can 


546  PRINCIPLES    OF    SURGERY. 

generally  be  recognized  by  bimanual  exploration,  especially  if  the  exami- 
nation is  made,  as  it  should  be,  under  the  influence  of  an  angesthetic.  A 
pelvic  abscess  is  always  preceded  by  an  acute  suppurative  parametritis  or 
perimetritis,  attended  by  severe  symptoms  which  are  absent  in  tubercular 
peritonitis.  Cystic  affections  of  the  gall-bladder,  pancreas,  and  kidney 
begin  in  the  upper  part  of  the  abdominal  cavity,  while  the  reverse  is 
usually  the  case  in  tubercular  ascites. 

The  greatest  difficulty  presents  itself  in  differentiating  between  a 
circumscribed  tubercular  ascites  and  an  ovarian  cyst.  So  close  is  the  clin- 
ical resemblance  of  these  two  affections  that  a  positive  diagnosis  is  almost 
impossible  without  the  aid  of  an  exploratory  laparotomy,  and,  as  both 
affections  can  only  be  treated  successfully  by  abdominal  section,  it  is  suffi- 
cient for  all  practical  purposes  to  narrow  the  diagnosis  down  to  one  of 
these  and  reserve  a  positive  diagnosis  until  the  abdomen  is  opened. 

Treatment. — The  surgical  treatment  of  tubercular  peritonitis  with 
effusion  by  laparotomy  has  yielded  sufficiently  satisfactory  results  to 
make  it  an  established  procedure  in  such  cases  in  the  future.  A  sponta- 
neous cure  is  the  exception;  death  from  local  extension  of  the  disease  and 
from  general  infection  the  rule.  A  case  came  under  my  observation  a 
few  years  ago  where  I  have  every  reason  to  believe  that  tubercular  ascites 
disappeared  spontaneously.  The  patient  was  a  woman,  40  years  of  age, 
with  a  marked  hereditary  tendency  to  tuberculosis,  several  sisters  having 
died  of  pulmonary  tuberculosis.  She  was  the  mother  of  several  children, 
the  youngest  being  6  years  old.  She  was  brought  to  me  by  her  family 
physician  with  the  diagnosis  of  ovarian  cyst.  She  had  been  ailing  for  two 
years.  When  I  examined  her  the  swelling  was  as  large  as  a  child's  head, 
occupying  the  hypogastric  and  left  iliac  region.  Fluctuation  distinct;  no 
pain  and  but  little  tenderness  on  pressure;  menstruation  regular.  Gen- 
eral health  only  slightly  impaired.  After  a  careful  examination  I  coin- 
cided with  the  diagnosis,  and  advised  an  early  operation.  Soon  after  this 
time  the  swelling  began  to  diminish  in  size  and  disappeared  completely  in 
the  course  of  a  year,  but  the  general  health,  instead  of  improving,  began 
to  fail.  After  the  disappearance  of  the  swelling  she  began  to  suffer  from 
a  deep-seated  pain  at  a  point  corresponding  to  the  cartilage  of  the  eighth 
rib  on  the  left  side,  and  in  the  course  of  a  few  months  a  fluctuating  swell- 
ing appeared  under  the  costal  arch  at  that  point.  Tuberculosis  of  the  ribs 
was  suspected,  but  at  the  time  of  operation  an  encapsulated  tubercular 
abscess,  was  found  in  the  abdominal  cavity,  to  the  left  of  the  great  curva- 
ture of  the  stomach  and  above  the  splenic  flexure  of  the  colon.  A  large 
quantity  of  liquefied,  caseous  material  was  evacuated.  The  wall  of  the 
abscess  was  lined  with  a  thick  layer  of  granulation-tissue,  which  was 
thoroughly  removed  with  a  sharp  spoon,  and  after  irrigation  the  cavity 


TUBERCULOSIS    OF    PEEITONEUM.  547 

was  carefully  dried  and  packed  with  iodoform  gauze.  The  wound  healed 
by  primary  intention,  and  the  entire  cavity  closed  in  the  course  of  four 
weeks  without  a  drop  of  pus.  The  woman  has  since  greatly  improved  in 
health  and  is  completely  relieved  of  her  pain.  There  can  hardly  be  a 
question  that  the  accumulation  of  fluid  which  was  mistaken  for  an  ovarian 
cyst  was  a  limited  ascites,  caused  by  a  circumscribed  tubercular  peritonitis, 
and  that  the  infection  in  the  upper  portion  of  the  abdominal  cavity  re- 
sulted from  this,  the  primary  depot.  It  is  not  at  all  improbable  that,  had 
an  operation  been  performed  at  the  time  it  was  advised,  this  extension  of 
the  infection  might  have  been  prevented. 

The  results  obtainable  by  laparotomy  in  the  two  different  forms  of 
tubercular  ascites  are  well  shown  by  two  cases  which  occurred  in  my  own 
practice.  The  first  patient  was  a  girl,  17  years  old,  without  a  tubercular 
history.  She  had  always  been  in  good  health  until  about  a  year  before  she 
came  under  my  observation,  when  she  commenced  to  suffer  from  pain  in 
the  left  iliac  region,  and  soon  after  a  perceptible  swelling  appeared  in 
that  locality,  which  gradually  increased  in  size  until  the  time  I  saw  her, 
when  it  reached  above  the  umbilicus  and  beyond  the  median  line.  Has 
never  menstruated.  Patient  was  ansemic  and  somewhat  emaciated,  but 
was  never  confined  to  bed.  Examination  revealed  no  disease  in  any  of  the 
important  organs.  Diagnosis  of  ovarian  cyst  had  been  made  by  several 
physicians.  The  abdomen  was  opened  by  a  median  incision,  and  a  large 
quantity  of  clear,  straw-colored  serum  escaped  as  soon  as  the  peritoneum 
was  incised.  The  parietal  peritoneum,  as  well  as  the  intestines,  which 
formed  a  part  of  the  wall  of  the  cavity,  were  studded  with  innumerable 
nodules  the  size  of  a  millet-seed.  These  nodules  were  largest  and  most 
numerous  in  the  region  of  the  left  Fallopian  tube,  which,  however,  was 
normal  in  size.  The  cavity  was  dried  and  freely  dusted  with  iodoform,  and 
a  Keith  glass  drain  inserted  as  far  as  the  floor  of  the  space  of  Douglas. 
A  large  quantity  of  serum  was  removed  from  the  tube  for  the  first  few 
days,  when  it  became  more  and  more  scanty,  so  that  the  glass  tube  could 
be  removed  at  the  end  of  the  second  week.  Through  a  small,  fistulous 
tract  serum  continued  to  escape  for  six  weeks,  when  the  fistula  closed. 
The  patient  gained  fifteen  pounds  in  weight,  and  a  year  after  the  operation 
was  in  perfect  health,  with  no  signs  of  a  local  return.  That  the  peritonitis 
in  this  case  was  tubercular  was  demonstrated  by  an  inoculation  experi- 
ment. A  nodule  was  removed  from  the  peritoneum  and  implanted  into 
the  peritoneal  cavity  of  a  guinea-pig,  with  a  positive  result.  The  second 
case  was  a  woman,  42  years  of  age,  without  any  history  of  tuberculosis  in 
her  family.  She  is  the  mother  of  a  large  family,  the  youngest  child  being 
5  years  of  age.  Her  abdomen  began  to  enlarge  four  months  before  she 
came  under  my  care.     Pain  not  severe,  but  gradual  loss  of  fiesh   and 


548  PRINCIPLES    OF    SURGERY. 

strength.  As  no  local  cause  for  the  ascites  could  be  found,  the  abdomen 
was  opened  in  the  median  line  and  at  least  two  pailfuls  of  clear  serum 
escaped.  The  intestines  and  parietal  peritoneum  presented  an  exceed- 
ingly vascular  apparance  and  were  studded  with  minute  miliary  nodules. 
These  nodules,  again,  were  largest  in  the  pelvis,  but  both  tubes  were  found 
in  a  normal  condition.  The  same  course  was  pursued  as  in  the  first  case, 
and  drainage  was  kept  up  for  two  weeks,  when  the  flow  of  serum  was  so 
scanty  that  it  was  deemed  advisable  to  remove  the  tube.  The  wound 
healed  completely  in  a  few  days,  and  the  patient  left  the  hospital  greatly 
relieved.  The  fluid,  however,  accumulated  so  rapidly  that  in  two  weeks 
she  had  to  be  tapped,  and  from  this  time  on  the  patient  could  not  leave 
her  bed.  The  tapping  had  to  be  repeated  every  two  weeks.  Symptoms  of 
pulmonary  phthisis  developed  soon  after  she  left  the  hospital,  and  death 
from  general  miliary  tuberculosis  occurred  in  less  than  three  months  after 
the  operation. 

The  danger  of  reaccumulation  of  fluid  and  general  infection  is  much 
greater  in  diffuse  tubercular  peritonitis  than  in  the  circumscribed  form, 
as  in  the  latter  the  area  of  infection  is  more  limited,  and  general  infection  is 
less  likely  to  occur  on  account  of  the  presence  of  a  wall  of  plastic  material 
which  surrounds  the  tubercular  field.  In  operating  for  circumscribed 
tubercular  ascites  it  is  very  important  to  exercise  great  care  in  opening 
the  abdominal  cavity,  as  a  loop  of  adherent  intestine  may  be  found  at  the 
point  where  the  incision  is  made.  The  peritoneum  must  be  recognized  and 
carefully  divided  in  order  to  prevent  wounding  of  the  bowel,  should  such 
a  condition  be  met  with.  lodoformization  of  the  cavity  is  one  of  the 
important  indications  of  treatment.  Drainage  must  be  maintained  until 
accumulation  of  serum  in  the  tube  has  ceased.  Uniform  equable  com- 
pression of  the  abdomen  with  strips  of  adhesive  plaster  or  a  well-fitting 
bandage  should  be  kept  up  throu.ghout  the  entire  after-treatment.  In 
cases  where  a  well-defined  local  tubercular  focus  is  found,  which  we  have 
reason  to  regard  as  the  cause  of  the  peritonitis,  this  should  be  removed  or 
rendered  harmless  by  appropriate  treatment.  A  tubercular  Fallopian  tube 
should  be  removed  if  this  can  be  done.  Other  caseous  foci  are  removed 
with  a  sharp  spoon,  or  they  can  be  destroyed  or  rendered  harmless  by 
ignipuncture  and  thorough  lodoformization. 

Lauenstein  attributes  the  curative  effect  of  laparotomy  in  cases  of 
tubercular  ascites  to  the  admission  of  atmospheric  air,  and,  acting  upon 
this  theory,  inflation  of  the  abdominal  cavity  after  tapping  has  been  re- 
sorted to  as  a  therapeutic  agent,  but  the  results  following  this  treatment 
have  not  been  encouraging.  Marchtthurn  reports  19  cases  of  tuberculosis 
of  the  peritoneum  treated  by  laparotomy  and  adds  to  these  17  additional 
cases  from  a  former  report.    Twenty-one  were  permanently  cured.    In  the 


TUBERCULOSIS    OF    PEEITONEUM.  549 

remaining  cases  in  which  tuberculosis  existed  in  other  organs  the  results 
consisted  only  in  temporary  improvement.  The  diagnosis  in  all  cases  was 
confirmed  by  microscopical  examinations.  Eoesch  collected  358  cases  sub- 
jected to  operative  treatment,  20  died  from  the  effects  of  the  operation, 
51  died  from  tuberculosis  in  other  organs,  and  250,  or  70  per  cent.,  were 
cured.  In  2  cases  of  limited  tubercular  ascites  the  writer  has  secured  ex- 
cellent results  from  tapping  followed  by  injection  of  4  drachms  of  a  10- 
per-cent.  emulsion  of  iodoform  in  glycerin.  Both  cases  resulted,  ap- 
parently, in  a  permanent  cure.  Both  patients  were  placed  at  the  same 
time  upon  the  internal  use  of  guaiacol.  I  have  since  treated  2  additional 
cases  in  the  same  manner  with  similar  results,  and  therefore  feel  confi- 
dent that  this  treatment  is  entitled  to  a  more  extended  trial. 


CHAPTER  XXII. 

TUBEKCULOSIS  OP  BONES  AND  JoiNTS. 
TUBEECULOSIS   OF   BONE. 

Next  to  the  lungs  and  lymphatic  glands,  the  bones  are  most  fre- 
quently the  seat  of  tubercular  infection.  Tuberculosis  of  the  bones  is 
an  exceedingly  frequent  affection  in  children  and  young  adults.  Its 
favorite  location  is  in  the  epiphyseal  extremities  of  the  long  bones,  al- 
though it  is  quite  frequently  met  with  in  the  short  bones  of  the  carpus 
and  tarsus  and  some  of  the  flat  and  irregular  bones,  as  the  ribs,  scapula, 
ileum,  and  vertebrae. 

Embolic  Infection  the  Cause  of  Osseous  Tuberculosis.  —  Practically, 
direct  tubercular  infection  does  not  occur,  and  when  the  disease  has  made 
its  appearance  it  is  only  an  evidence  of  the  existence  of  a  tubercular  focus 
in  some  other  organ.  We  observe  clinically,  what  Mueller  has  demon- 
strated experimentally,  that,  when  the  bacilli  of  tuberculosis  are  present 
in  the  blood-current,  very  often  localization  takes  place  near  the  epiph- 
yseal cartilage  in  young  persons  by  the  microbes  becoming  arrested  in 
one  of  the  terminal  branches  of  an  artery,  the  lumen  of  which  becomes 
obliterated  by  the  presence  of  a  minute  embolus  of  granulation-tissue  con- 
taining bacilli;  or  the  lumen  of  the  vessel  is  gradually  diminished  by  the 
formation  of  a  mural  thrombus,  which  forms  around  bacilli  implanted 
upon  the  vessel-wall,  and  the  vessel  is  finally  completely  obstructed  by  the 
growth  of  the  thrombus. 

The  new  vessels  in  the  vicinity  of  the  centres  of  growth  in  the  bones 
of  young  persons,  on  account  of  their  imperfect  structure  and  irregular 
contour,  furnish  the  most  favorable  conditions  for  the  arrest  of  floating 
granular  matter  and  the  localization  of  pathogenic  microbes.  The  pre- 
disposing anatomical  element  goes  far  to  explain  the  frequency  with  which 
we  meet  with  tubercular  foci  in  the  epiphyseal  extremities  of  the  long 
bones. 

The  following  table,  prepared  by  Schmallfuss,  gives  a  good  idea  of 
the  relative  frequency  with  which  different  bones  are  affected  with  tuber- 
cular lesions: — 

(550) 


Fig.  184.— Tuberculosis  of  the  Lower  Epiphysis  of  the  Humerus. 


TUBEECULOSIS    OP   BONE. 


551 


Billroth. 

Jaffb. 

Per  Cent. 

SCHMALLFUSS. 

Per  Cent. 

Vertebra. 

Vertebra. 

26 

Knee. 

23 

Knee. 

Foot. 

21 

Foot. 

19 

Cranium  and  Face. 

Hip. 

13 

Hip. 

16 

Hip. 

Knee. 

10 

Elbow. 

9 

Sternum  and  ribs. 

Hand. 

9 

Hand. 

8 

Foot. 

Elbow. 

4 

Vertebra. 

7.5 

Elbow. 

Pelvis. 

3 

Tibia. 

4 

Pelvis. 

Cranium. 

3 

Cranium. 

4 

Tibia,  Fibula,  and 

Sternum,  Clavicle, 

Pelvis. 

3.6 

Femur. 

and  Ribs. 

3 

Sternum,  etc. 

8.6 

Shoulder. 

Shoulder. 

2 

Femur. 

1.9 

Femur. 

1 

Shoulder. 

1.5 

Humerus. 

Tibia. 

1 

Ulna. 

1.4 

Ulna. 

Fibula. 

1 

Humerus. 

3 

Eadius. 

Humerus. 

1 

Radius. 

0.7 

Scapula. 

Scapula. 

0.6 

Fibula. 

0.5 

Ulna. 

0.6 

Patella. 

0.1 

It  is  safe  to  state  that  before  puberty  the  primary  lesion  in  tuber- 
cular affections  of  joints  is  located  in  one  or  both  of  the  epiphyses  of 
the  bones  which  enter  into  the  formation  of  a  joint,  while  in  the  adult 
primary  tuberculosis  of  the  synovial  membrane  is  of  more  frequent  oc- 
currence. As  age  advances  and  the  process  of  ossification  is  completed, 
the  predisposing  localizing  causes  in  bone  apparently  disappear,  while  the 
synovial  membrane  becomes  more  susceptible  to  primary  localization.  Of 
204  specimens  of  tubercular  joints  obtained  from  patients  of  all  ages, 
examined  by  Mueller,  158  were  primary  osteal  and  46  primary  synovial 
tuberculosis. 

Artificial  Tuberculosis  of  Bone  Produced  by  Direct  Intravascular  In- 
fection.— William  Mueller,  formerly  one  of  Konig's  assistants,  produced 
the  characteristic  clinical  form  of  tuberculosis  in  bone  experimentally 
by  injecting  tubercular  material  into  the  nutrient  artery  of  long  bones. 
Konig  for  a  long  time  had  claimed  that  the  wedge-shaped  sequestrum,  so 
constantly  found  in  tubercular  foci  in  the  articular  extremities  of  the 
long  bones,  was  due  to  occlusion  of  a  small  artery  by  a  tubercular  embolus. 
Mueller's  experiments  were  undertaken  to  produce  this  condition  arti- 
ficially. He  made  16  experiments  on  rabbits,  injecting  tubercular  pus  into 
the  femoral  artery,  some  in  a  peripheral,  some  in  a  central  direction,  with- 
out any  positive  results  following.  In  a  second,  series  the  same  material 
was  thrown  directly  into  the  nutrient  arteries  of  the  femur  and  tibia.  Of 
10  of  these  cases,  2  showed  a  tubercular  focus  in  the  medulla  of  the  diaph- 
ysis  of  the  tibia;  in  another  case  miliary  tuberculosis  in  the  femur  and 
tibia,  and  in  the  latter  bone  a  small  caseous  nodule  in  the  spongy  part 
which  contained  numerous  bacilli.  The  animals  were  killed  eight  weeks 
after  injection,  and  showed  no  evidences  of  organic  disease  except  a 
few  tubercles  in  the  lungs.     Twenty  experiments  were  made  on  young 


553  PRINCIPLES    OF    SURGERY. 

goats,  5  on  sheep,  and  2  on  dogs.  The  tubercular  material  was  injected 
directly  into  the  nutrient  artery  of  the  tibia,  the  tibial  artery  being  tied 
above  and  below  the  junction  with  this  vessel.  Primary  union  of  the 
wound  was  obtained  in  all  cases  except  in  1  dog.  In  the  dogs  and  sheep 
all  experiments  resulted  negatively.  In  the  goats  bone  affections  were 
produced  that  were  identical  with  tubercular  bone-lesions  found  in  man. 
Most  frequently  the  disease  was  established  in  the  diaphysis,  cheesy 
masses  and  granulation-tissue  showing  themselves  in  the  medulla  and 
cortical  portion  of  the  bone,  or  tubercular  osteomyelitis  with  or  without 
sequestration.  Typical  lesions  were  also  found  in  the  ends  of  the  bones, 
with  and  without  implication  of  the  adjacent  joints.  In  2  of  these  cases 
the  epiphysis  was  affected,  while  in  3  the  shaft  was  involved.  The  follow- 
ing experiment  made  by  him  furnishes  a  good  illustration  of  the  identity 
of  the  bone  disease  produced  experimentally  with  the  disease  as  it  occurs 
in  man. 

Tubercular  material  was  injected  into  the  tibial  artery  of  a  goat  3 
months  old.  Wound  healed  in  eight  days.  Some  lameness  four  months 
later,  gradually  increasing  during  the  next  nine  months.  At  the  same 
time  a  swelling  appeared  at  the  knee-joint.  Tibia  painful  on  outer  side. 
Animal  killed  thirteen  months  after  the  injection.  At  the  necropsy  there 
was  found  a  typical  fungous  disease  in  the  knee-joint,  most  advanced  at 
the  lateral  aspects  of  the  joint;  a  wedge-shaped  sequestrum  in  one  of  the 
tuberosities  of  the  tibia,  a  small  granulation-mass  in  the  centre  of  the  head 
of  the  tibia,  and  two  similar  granulation-masses  in  the  lower  epiphysis  of 
the  femur.  Excepting  the  lymphatic  glands  of  the  knee-joint,  no  other 
organs  were  affected.  In  some  of  the  cases,  pulmonary  tuberculosis,  twice 
general  miliary  tuberculosis.  The  remainder  of  the  animals  were  killed 
when  they  began  to  show  lameness:  fourteen  days  to  thirteen  months 
after  infection.  The  tubercular  lesions  thus  produced  were  examined  for 
bacilli,  and  these  were  never  found  absent.  The  starting-point,  in  every 
instance,  must  have  been  a  tubercular  embolus  in  one  of  the  ultimate 
minute  branches  of  the  nutrient  artery  near  the  epiphyseal  extremity  of 
the  bone. 

Clinical  and  Bacteriolog"ical  Researches. — Schuchardt  and  Krause  ex- 
amined a  great  variety  of  tubercular  lesions,  and  came  to  the  conclusion 
that  tubercle  bacilli  can  be  found  in  them  without  exception,  but,  as  a 
rule,  few  in  number,  and  often  only  to  be  detected  after  long  and  patient 
search.  They  found  them  invariably  present  in  cases  of  secondary  and 
primary  tuberculosis  of  synovial  membranes,  tuberculosis  of  bone,  in  tuber- 
cular abscesses,  and  in  the  latter  cases  not  in  the  fluid  contents,  but  in 
the  granulations  lining  the  abscess-wall.  Eenken  found  the  bacillus  of 
tuberculosis  in  all  cases  of  spina  ventosa  which  he  examined.     Mueller 


TUBEECULOSIS    OF    BONE.  553 

carefully  studied  numerous  specimens  of  synovial  and  bone  tuberculosis, 
with  special  reference  to  the  existence  of  the  bacillus  of  tuberculosis,  and, 
although  the  results  in  a  number  of  cases  were  negative,  he  believes  that 
the  most  intimate  and  direct  etiological  relations  exist  between  the  bacil- 
lus and  all  tubercular  lesions  in  bones  and  joints.  Among  others  who  have 
shown  the  never-failing  presence  of  the  bacillus  in  different  forms  of 
surgical  tuberculosis,  including  bones  and  joints,  may  be  mentioned 
Kanzler,  Mogling,  Bouilly,  and  Letulle.  Tuberculosis  of  bone  and  fungous 
disease  of  joints,  like  lymphatic  tuberculosis,  have  been,  and  by  some  are 
still,  regarded  as  scrofulous  affections.  Kanzler  wished  to  make  a  dis- 
tinction between  scrofula  and  tuberculosis,  as  he  fonnd  the  bacilli  not  as 
constant  in  the  former,  and  observed  that,  after  implantation  of  tissue 
of  what  he  regarded  as  scrofulous  affections  of  animals,  the  process  was 
slower  than  after  inoculation  with  the  products  of  recognized  forms  of 
tuberculosis.  Letulle  considers  scrofula  and  tuberculosis  as  belonging  to 
one  and  the  same  disease,  of  which  the  former  constitutes  the  milder  form, 
and  appearing  externally,  while  the  latter  represents  the  graver  form, 
attacking  by  preference  the  internal  organs.  The  points  made  by  the 
last  two  authors  are  too  unimportant  for  further  consideration  as  a  scien- 
tific, or  even  practical,  distinction  between  scrofula  and  tuberculosis  as 
applied  to  affections  of  the  bones  or  any  other  organs.  TTie  surgeon  must 
recognize  every  lesion  as  tubercular  in  its  origin,  nature,  and  course  in  ivhicJi 
the  iacillus  of  tuberculosis  can  be  found,  from  luhich  successful  cultivations 
can  be  made,  and  with  which  the  disease  can  be  artificially  produced  in  ani- 
mals by  inoculation.  The  presence  of  the  bacillus  of  tuberculosis  in  the 
body  and  its  localization  in  the  medullary  tissue  of  bone  is  the  conditio 
sine  qua  non  in  the  causation  of  osseous  tuberculosis.  The  influence  of 
traumatism  in  the  etiology  of  tuberculosis  of  the  bones  and  joints  has 
been  greatly  overestimated.  Traumatism  as  an  etiological  factor  occupies 
a  subordinate  role,  inasmuch  as  it  can  only  be  an  exciting  cause  in  persons  al- 
ready infected  with  the  essential  cause.  Max  Schiiller  proved  experimentally 
in  animals  infected  with  tuberculosis  (for  instance,  through  the  respiratory 
tract)  that  a  slight  traumatism  to  a  joint  would  determine  localization  of  the 
microbes  floating  in  the  blood-current  in  the  part  injured,  and  that  a  tuber- 
cular synovitis  or  pararthritis  would  follow. 

On  the  other  hand,  Lannelongue  and  Achard,  in  an  experimental  in- 
vestigation regarding  the  influence  of  trauma  in  the  production  of  tuber- 
culosis, infected  guinea-pigs  and  then  produced  various  injuries.  The 
animals  died  of  general  tuberculosis,  but  in  no  case  were  they  able  to  dis- 
cover evidences  of  local  tuberculosis  at  the  seat  of  injury. 

Clinically,  tuberculosis  of  the  bones  can  be  traced  only  in  a  small  per- 
centage of  the  cases  to  a  traumatic  origin.    It  is,  as  Volkmann  asserted  long 

35a 


554  PEiNCiPLES  or  surgery. 

ago,  characteristic  tliat  the  traumatism  is  always  slight,  often  quite  in- 
significant; tuberculosis  of  bone,  even  in  tubercular  subjects,  seldom,  if 
ever,  follows  a  fracture,  as  the  injury  in  such  cases  is  productive  of  such 
active  cell-proliferation  that  will  neutralize  the  pathogenic  action  of  the 
bacilli  which  might  reach  the  seat  of  injury  with  the  extravasated  blood. 
It  is  also  possible  that  in  many  cases,  at  least,  the  attention  of  the  patient 
or  his  friends  is  first  accidentally  called  to  an  existing  tubercular  focus 
by  the  immediate  efl:ects  of  the  injury,  the  latter  having  had  no  influence 
in  the  causation  of  the  disease.  Every  child  large  enough  to  run  around 
injures  himself  more  or  less  (almost)  daily,  and  yet  tuberculosis  of  the 
bones  and  joints  follows  as  a  consequence  only  in  comparatively  few,  and 
in  such  cases  the  essential  cause  must  be  present  in  the  blood  or  tissues 
at  the  time  the  injury  is  received.  As  has  been  previously  stated,  what  is 
generally  regarded  as  local  bone  tuberculosis  (by  which  we  mean  the  ab- 
sence of  recognizable  tubercular  lesions  in  other  organs)  is  in  reality  a 
secondary  disease,  resulting  from  the  introduction  of  bacilli  through  the 
respiratory  or  alimentary  tract  into  the  circulating  blood,  with  localization 
in  the  bone,  or  the  entrance  of  bacilli  into  the  circulation  from  a  preexist- 
ing, but  undetectable,  tubercular  product,  with  secondary  localization  in 
bone.  In  this  sense  a  primary,  or,  to  use  a  more  correct  expression,  a 
localized  osseous  or  articular  tuberculosis  is,  according  to  Kummer,  found 
in  about  40  per  cent,  of  the  cases;  in  the  remaining  60  per  cent,  depots 
are  found  at  the  same  time  in  other  organs  of  the  body;  the  lung  comes 
first,  with  25  per  cent.;  other  joints,  10  per  cent.;  other  bones,  10  per 
cent.;  lymphatic  glands,  10  per  cent.;  peritoneum,  3  per  cent.;  pleura,  2 
per  cent. 

Pathology  and  Morbid  Anatomy. — The  tubercle  bacillus  has  a  special 
predilection  for  the  medullary  tissue  of  the  bones,  and  especially  for  the 
red  medullary  tissue  in  the  cancellated  tissue  in  the  region  of  the  epiph- 
yseal cartilage  of  the  long  bone.  As  an  inflammatory  affection,  it  is 
more  correct  to  speak  of  tubercular  osteomyelitis  than  tuberculosis  of 
bone,  since  the  medullary  tissue  and  the  blood-vessels  which  it  contains 
are  the  parts  that  take  an  active  part  in  the  inflammatory  process.  The 
anatomical  conditions  of  the  vessels  in  the  epiphyseal  region  of  the  long 
bones  in  young  persons,  and  in  the  vessels  of  the  medullary  tissue,  favor 
implantation  of  the  microbes  upon  the  vessel-wall,  and  they  also  explain 
the  frequency  with  which  localization  of  the  tubercular  process  takes 
place  in  this  locality.  The  shaft  of  the  long  bones  is  generally  exempt 
from  tubercular  disease  Avith  the  exception  of  the  phalanges  of  the  fingers 
and  toes  and  the  metacarpal  and  metatarsal  bones  in  children,  where  the 
tubercular  osteomyelitis  gives  rise  to  the  well-known  spina  ventosa  of  the 
old  authors.     As  soon  as  embolic  infection  in  bone  has  taken  place  a 


Fig.  185.— Caries  of  Fourth  Metacarpal  Bone  before  Operation.     (Sanger  Brown.) 


TUBEECULOSIS    OF   BONE.  555 

process  of  osteoporosis  and  decalcification  occurs  around  the  tubercular 
embolus  or  thrombus,  and  the  preexisting  medullary  and  connective  tis- 
sues are  transformed  into  embryonal  or  granulation  cells,  which  impart 
to  the  product  of  the  specific  inflammation  its  characteristic  fungous  ap- 
pearance. It  is  not  often  that  only  a  single  focus  of  tubercular  infection 
in  bone  is  present;  more  frequently  two  or  three  foci  appear  in  the  same 
region  simultaneously  or  in  slow  or  rapid  succession,  and  it  is  not  unusual 
to  find  that  two  neighboring  epiphyses  are  infected  at  the  same  time  or 
during  the  course  of  the  disease.  In  bone  the  granulation-tissue  under- 
goes the  same  series  of  secondary  degenerative  tissue-changes  as  in  the 
lymphatic  glands;  hence  in  advanced  cases  we  expect  to  meet  with  casea- 
tion, liquefaction  of  the  cheesy  material,  and  suppuration  in  cases  of  sec- 
ondary infection  with  pyogenic  microbes.  The  obstruction  of  a  small 
artery  by  an  embolus  or  thrombus  which  contains  tubercle  bacilli  usually 
leads  to  necrosis  and  sequestration  of  a  triangular  piece  of  bone,  which, 
in  its  outlines,  marks  the  area  of  tissue  which  received  its  blood-supply 


Fig.  186. — Tubercular  Focus  near  the  Epiphyseal  Line  of  the  Lower  End  of  the  Femur. 

from  the  obstructed  vessel;  thus  the  triangular  sequestra  are  formed  that 
are  so  frequently  met  with  in  osteal  tuberculosis  of  the  epiphyseal  ex- 
tremities. If  the  embolus  is  located  on  the  side  of  the  epiphyseal  cartilage 
toward  the  joint,  the  base  of  the  triangular  sequestrum  is  directed  toward 
the  joint,  and  not  infrequently  projects  slightly  into  the  joint.  It  is 
seldom  that  tuberculosis  of  bone  develops  in  the  course  of  pulmonary 
tuberculosis,  but  pulmonary  and  diffuse  miliary  tuberculosis  can  be  traced 
frequently  to  a  tubercular  osseous  focus.  The  intimate  relations  which 
exist  between  the  tubercular  nodule  in  bone  and  the  blood-vessels  furnish 
a  satisfactory  explanation  of  the  frequency  with  which  systemic  infection 
takes  place.  A  person  once  infected  with  the  bacillus  tuberculosis  is  liable 
to  suffer  from  the  different  forms  of  localized  tuberculosis,  and  finally 
dies  of  pulmonary  or  general  miliary  tuberculosis.  Volkmann  has  well 
said  that  a  child  suffering  from  glandular  tuberculosis  has  a  good  chance 
to  become  the  subject  of  osseous  tuberculosis  during  adolescence,  and  to 
die  of  pulmonary  tuberculosis  before  reaching  the  age  of  30.    As  soon  as 


556  PEINCIPLES    OF    SURGERY. 

the  granulation  process  in  bone  reaches  an  adjacent  vein,  the  tissues  con- 
stituting the  vein-wall  undergo  the  same  process,  the  bacilli  reach  the 
lumen  of  the  vessel  and  reenter  the  systemic  circulation,  and  give  rise  to 
miliary  tuberculosis  in  organs  which  are  anatomically  predisposed  to 
secondary  infection.  As  long  as  decalcification  of  the  surrounding  bone 
goes  on  the  infection  is  progressive,  but  as  soon  as  osteosclerosis  takes  its 
place  the  process  becomes  limited:  the  microorganisms  are  shut  in,  as  it 
were,  by  an  impermeable  wall  of  sclerosed  bone.  The  most  unfavorable 
conditions  are  created  in  cases  in  which  the  tubercular  focus  becomes  the 
seat  of  secondary  infection  with  pyogenic  microbes,  as  the  suppurative 
process  opens  up  to  the  bacillus  of  tuberculosis  new  areas  for  invasion  in 
which  the  resistance  of  the  tissues  to  tubercular  infection  has  already  been 
greatly  diminished.  It  is  also  during  the  suppurative  stage  that  Joint- 
complications  are  most  likely  to  arise.  The  clinical  history  of  cases  of 
tuberculosis  of  bone,  as  well  as  the  macroscopical  and  microscopical  ap- 
pearances of  the  lesion,  are  typical  of  tuberculosis  as  found  in  other  oragns. 
The  crucial  test  which  proves  the  tubercular  character  of  most  of  the 
chronic  inflammatory  afl^ections  of  bone  in  children  has  been  furnished  by 
bacteriological  investigations  and  experimental  research.  Most  of  the  in- 
vestigators who  have  studied  this  subject  agree  that  in  tubercular  bone 
affections  it  is  sometimes  very  difficult  to  find  the  bacillus,  that  it  is  not 
found  in  great  abundance,  and  that  sometimes  it  has  evaded  even  the  most 
careful  search.  According  to  Konig,  who  is  authority  on  everything  that 
pertains  to  tuberculosis  of  bones  and  Joints,  all  cases  of  osteotuberculosis 
can  be  arranged  under  four  principal  groups,  according  to  the  predomi- 
nating pathological  conditions  of  the  lesions:  1.  The  granulating  focus. 
2.  The  tubercular  necrosis.  3.  The  tubercular  infarct.  4.  Difliuse  tuber- 
cular osteomyelitis. 

1.  The  granulating  focus  is  found  as  single  or  multiple,  round  or  oval, 
cavities,  from  the  size  of  a  millet-seed  to  that  of  a  pea  or  hazel-nut,  con- 
taining living  embryonal  tissue,  or,  if  this  has  been  destroyed  by  coagula- 
tion-necrosis and  caseation,  a  yellowish-gray,  cheesy  material,  or  liquid  tuber- 
cular pus.  Minute  spieulse  of  bone  are  imbedded  among  the  granulations  or 
suspended  in  the  liquefied  caseous  material.  Histologically,  the  granulation- 
material  is  comiDosed  of  the  same  cell-elements  as  recent  tubercle  in  other 
organs,  only  that,  as  a  rule,  the  giant  cells  are  more  numerous  and  of  larger 
size.  If  caseation  has  taken  place  the  cheesy  material  is  surrounded  by  a 
zone  of  granulation-tissue.  As  long  as  the  process  has  not  come  to  a  stand- 
still the  surrounding  bone  is  osteoporotic,  and  can  be  easily  scraped  out  with 
a  sharp  spoon.  As  soon  as  the  inflammatory  process  has  subsided  the  osteo- 
porotic bone  becomes  sclerosed  and  the  tubercular  focus  is  walled  in  and,  for 
the  time  being,  is  rendered  harmless.     Cheesy  tubercular  cavities  in  bone 


TUBEECULOSIS    OF    BONE. 


557 


resemble  the  same  condition  in  the  lungS;,  only  that  secondary  infection  with 
pus-microbes  is  of  less  frequent  occurrence,  and  on  this  account  the  cavity 
never  attains  such  large  size  as  in  the  latter  organ. 

2.  Tubercular  necrosis  necessarily  follows  if  the  infected  area  exceed 
the  size  of  a  hazel-nut.  The  non-vascular  structure  of  the  tubercular  product 
and  the  blocking  and  destruction  of  blood-vessels  during  the  early  stages  of 


(ry^^J^^^^-'-^^^'y- '  -*•''""  °  °  ~  °'°  ••»=■'■  "> '  - "' 


-K 


§%'^fepS-^'5iv:^-'^/^v 


Pig.  187. — Tuberculosis  of  Astragalus.     Tu,  fungous  granulations  and  tubercle 
in  spongiosa;    K,  remaining  laminse.     (Tillmanns.) 

the  tubercular  inflammation  produce  early  death  of  the  bone,  corresponding 
to  the  limits  of  the  inflammation,  and  if  this  exceed  the  resorption  capacity 
of  the  granulations  the  dead  tissue  is  not  removed  by  absorption,  and  is  found 
as  a  sequestrum  as  soon  as  it  has  become  detached  from  the  surrounding- 
healthy  bone.  If  the  tubercular  process  has  been  rapid  and  the  granulation- 
tissue  is  scanty,  the  necrosed  bone  is  not  osteoporotic;  but  if  the  disease  has 
pursued  a  more  chronic  course,  and  has  resulted  in  the  production  of  an 


Fig.  188. — Tubercular  Sequestra.     (Landerer.) 


abundance  of  granulation-tissue,  it  j)resents  a  honey-combed  appearance,  is 
irregular  in  shape  and  in  size,  does  not  correspond  with  the  area  of  the  in- 
fected district,  as  part  of  it  has  been  absorbed  by  the  granulations.  Its  color 
depends  on  the  condition  of  the  granulations  which  surround  it;  if  these 
have  not  undergone  secondary  degenerative  changes  it  may  resemble  healthy 
bone,  but  if  caseation  has  taken  place  it  is  infiltrated  with  cheesy  mate- 


558  PRINCIPLES    OF    SURGERY. 

rial,  and  then  presents  a  grayish-yellow  or  yellow  appearance.  If  the  ne- 
crosed bone  has  undergone  no  reduction  in  size,  and  the  granulations  sur- 
rounding it  are  few,  it  remains  firmly  wedged  in  position,  and  under  such 
circumstances  it  is  often  difficult  to  locate  the  exact  boundary-line  between 
it  and  the  surrounding  healthy  bone  or  to  dislodge  it  from  its  position. 

3.  The  tubercular  infarct  is  only  another  form  of  tubercular  necrosis, 
and  is  separately  classified  because  the  necrosed  bone  is  always  wedge-shaped, 
and  the  necrosis  has  been  caused  by  the  impaction  of  an  embolus  containing 
tubercle  bacilli  in  a  distal  branch  of  a  nutrient  artery.  The  size  of  the  vessel 
obstructed  by  an  infected  embolus  will  determine  the  extent  of  the  necrosis. 
If  the  embolus  is  small,  the  area  of  necrosis  may  be  increased  by  the  blocked 
vessel  becoming  the  seat  of  secondary  thrombosis,  obliteration  of  the  vessel 
taking  place  in  a  proximal  direction  by  growth  of  the  thrombus  toward  the 
heart.    As  the  cortical  portion  of  the  bone  is  seldom  involved  by  a  tuber- 


Fig.  189. — Tubercular  Infarct  in  the  Head  of  the  Femur.     Cartilage  separated  from 
the  wedge-shaped  sequestrum.     (Volkmann.) 

cular  infarct,  the  necrosed  area  is  often  overlooked  in  operations  on  tuber- 
cular joints  unless  the  bone  is  sawn  through.  If  the  base  of  the  wedge- 
shaped  piece  project  into  a  joint  that  has  been  used,  its  surface  will  be  found 
smoothly  polished  by  the  movements  in  the  joint.  Separation  of  the  seques- 
trum takes  place  more  slowly  than  after  suppurative  osteomyelitis,  the  proc- 
ess requiring  often,  according  to  the  size  of  the  sequestrum  and  the  activity 
of  the  inflammatory  process,  months  and  years  for  its  completion.  If  the 
granulations  which  surround  the  sequestrum  do  not  undergo  cheesy  degen- 
eration, the  bone  becomes  imbedded  and  fits  accurately  into  the  cavity,  and 
if  the  surrounding  zone  of  granulation  is  converted  into  connective  tissue 
it  may  become  permanently  encapsulated;  but  even  from  such  an  apparently 
healed  depot  local  and  general  infection  can  occur  at  any  time. 

4.  The  diffuse  form  of  tubercular  osteomyelitis  is  quite  rare.  The 
pathological  and  clinical  characteristics  of  this  form  of  local  tuberculosis 
consist  in  the  rapid  local  extension  of  the  affection  and  the  danger  to  life 


TUBEECULOSIS    OF    BONE.  559 

from  general  infection.  On  making  a  longitudinal  section  throngh  a  long 
bone  affected  by  diffuse  tubercular  osteomyelitis,  we  observe  conditions 
which  closely  resemble  acute  suppurative  osteomyelitis.  We  find  largCj 
irregular,  often  multiple  areas  of  a  yellowish-white  infiltration  with  multi- 
ple foci  of  liquefied  cheesy  material.  The  infection  extends,  as  in  cases  of 
suppurative  osteomyelitis,  along  the  blood-vessels  and  Haversian  canals  to 
the  periosteum,  resulting  in  diffuse  plastic  periostitis  with  the  formation  of 
irregular,  diffuse  masses  of  bone.  In  these  cases  there  is  no  tendency  to  lim- 
itation in  the  formation  of  sequestra,  but  rather  a  tendency  to  spread  in- 
definitely, and  to  invade  even  the  medullary  tissue  of  the  shaft.  Patients 
suffering  from  this  form  of  tubercular  osteomyelitis  are  exposed  to  the  dan- 
gers of  a  fatal  general  tuberculosis  if  the  infected  tissues  are  not  removed  by 
a  timely  and  thorough  operation.    In  operating  it  is  important  to  recognize 


Fig.  190. — Tubercular  Debris  from  Caseated  Nodule.    Tubercle  bacilli  mixed  with  necrotic 
cell-elements.     (Stained  by  Ziehl's  carbol-fuchsin  and  Loeffler's  methylene-blue.) 

this  form,  since  it  requires  more  radical  measures:  either  amputation  or  very 
extensive  excision  of  the  entire  thickness  of  the  affected  bone.  Local  opera- 
tions such  as  will  meet  the  indications  in  the  other  varieties  of  osteotuber- 
culosis  are  of  no  avail.  With  the  exception  of  this  form  of  tuberculosis  of 
bone  the  periosteum  seldom  participates  in  the  tubercular  inflammation. 
When  the  dry  granulating  focus  reaches  the  periosteum,  a  small,  soft,  elastic^ 
limited  granulation  swelling  forms:  first  under  the  periosteum,  later  outside 
of  it.  It  is  characterized  by  slow  growth,  comparatively  little  pain,  slight 
tenderness,  and  a  tendency  to  remain  stationary  for  a  long  time.  If,  how- 
ever, the  central  focus  has  become  cheesy,  and  the  liquefied  cheesy  material 
comes  in  contact  with  the  periosteum  and  the  paraperiosteal  tissues,  a  large 
tubercular  abscess  forms  in  a  short  time.  As  soon  as  the  periosteum  has  been 
perforated  the  cheesy  material  infects  the  connective  tissue,  which  then  takes 


560  PRINCIPLES    OF    SURGEEY. 

an  active  part  in  the  formation  of  the  tubercular  abscess.  Before  such  an 
abscess  ruptures  spontaneously  the  skin  overlying  it  becomes  tubercular  and 
jDresents,  at  the  point  of  perforation,  the  appearance  of  lupus. 

Symptoms  and  Diagnosis. — ^The  general  symptoms  are  often  no  indica- 
tion of  the  existence  or  extent  of  the  local  disease,  as  patients  with  quite 
extensive  osteotuberculosis  may  present  every  appearance  of  perfect  health. 
More  than  twenty  years  ago  Konig  called  our  attention  to  the  fact  that  a 
slight  rise  in  the  temperature  is  frequently  present  even  in  cases  of  limited 
local  tuberculosis.  If  the  thermometer  show  a  normal  morning  temperature 
and  a  slight  rise  toward  evening,  if  not  more  than  half  a  degree  Fahrenheit, 
but  continued  for  weeks,  it  indicates  a  careful  search  for  a  local  tubercular 
focus.  Progressive  anaemia  is  always  an  unfavorable  symptom,  as  it  indi- 
cates either  the  presence  of  additional  foci  in  important  organs  or  accom- 
panies the  exhaustive  purulent  discharges  after  secondary  infection  with 
pus-microbes.  The  occurrence  of  mixed  infection,  with  or  without  a  direct 
infection-atrium,  is  usually  announced  by  a  high  temperature  and  other 
symptoms  of  septic  infection.  The  local  symptoms  vary  according  to  the 
location,  condition,  and  size  of  the  tubercular  focus  and  the  presence  or  ab- 
sence of  complications. 

1.  Pain. — Pain  is  an  almost  constant  symptom,  but  its  intensity  is  sub- 
ject to  great  variation.  Unlike  in  acute  suppurative  osteomyelitis,  the  in- 
flammatory product  does  not  give- rise  to  the  same  degree  of  tension;  hence 
pain  is  not  so  severe.  The  primary  exudation  in  tubercular  inflammation  is 
always  scanty,  and  the  inflammatory  product  is  composed  mostly  of  granu- 
lation-tissue derived  from  preexisting  cells;  at  the  same  time  the  surround- 
ing bone-tissue  becomes  osteoporotic,  consequently  tension  is,  to  a  great 
extent,  avoided  and  pain  is  either  slight  or  entirely  absent.  Children  suf- 
fering from  spina  ventosa  complain  of  little  pain,  although  a  phalanx  of  a 
finger  may  be  almost  completely  destroyed  by  a  tubercular  osteomyelitis. 
In  such  cases  the  granulation-tissue  is  formed  slowly,  the  compact  layer  of 
the  bone  is  rendered  osteoporotic,  and  generally  yields  to  the  intraosseous 
pressure  and  expands  perhaps  to  twice  its  normal  thickness;  j)aiii  is  slight 
or  entirely  absent,  because  no  great  intraosseous  tension  has  occurred.  That 
tension  or  pressure  greatly  aggravates  pain  in  osseous  tuberculosis  is  one  of 
the  most  familiar  facts  in  surgery.  Pain  is  promptly  relieved  in  a  case  of 
tubercular  spondylitis  by  suspension  and  rest  in  the  recumbent  position, 
and  greatly  aggravated  by  flexion  of  the  spinal  column,  which  necessarily 
produces  pressure  upon  the  bodies  of  the  inflamed  vertebra.  In  osteoar- 
thritis of  the  large  joints  pain  is  relieved  by  rest  and  extension,  and  is  always 
increased  by  use  of  the  limb  or  by  pressing  the  inflamed  articular  surfaces 
against  each  other.  It  may  be  stated,  as  a  rule,  that  the  intensity  of  the  pain 
bears  a  direct  relationship  to  the  acuteness  of  the  inflammatory  process.    The 


TUBERCULOSIS    OF    BONE.  561 

pain  is  intermittent  and  more  severe  during  the  night.  The  nocturnal  ex- 
acerbation of  the  pain,  as  evidenced  in  children  by  restlessness  during  sleep, 
moaning,  grinding  of  teeth,  and  horrible  dreams,  is  often  one  of  the  first 
symptoms  which  excites  suspicion  of  the  existence  of  osteotuberculosis.  The 
pain  is  not  always  referred  to  the  seat  of  lesion.  Tubercular  osteomyelitis  of 
the  head  and  neck  of  the  femur  gives  rise  to  pain  in  the  region  of  the  knee- 
joint,  and  children  suffering  from  tuberculosis  of  the  spine  usually  refer  all 
the  suffering  to  the  pit  of  the  stomach  or  to  some  other  part  of  the  abdomen 
supplied  with  nerves  that  take  their  exit  from  the  spinal  canal  at  a  point 
corresponding  to  the  inflamed  vertebra. 

2.  Tenderness. — The  presence  of  tenderness  over  a  point  corresponding 
to  a  tubercular  focus  in  the  interior  of  a  bone  is  one  of  the  surest  indications 
of  the  existence  of  osteotuberculosis.  In  many  cases  of  epiphyseal  tubercu- 
losis patients  have  been  treated  for  some  supposed  lesion  in  the  adjacent 
joint  simply  because  this  symptom  was  not  carefully  searched  for,  or,  if  dis- 
covered, its  significance  was  misinterpreted.  In  such  cases  the  existence  of 
a  circumscribed  point  of  tenderness  in  the  epiphyseal  line  and  the  absence  of 
lesions  in  the  joint  will  enable  the  surgeon  to  locate  accurately  a  focus  in  the 
interior  of  a  bone.  If  more  than  one  focus  is  present  in  the  epiphyseal  ex- 
tremity of  a  long  bone,  the  number  of  tender  points  will  correspond  with  the 
number  of  foci  in  the  bone.  Whether  a  central  focus  in  a  bone  could  be 
always  recognized  by  relying  upon  this  symptom  is  somewhat  doubtful,  but 
usually  the  foci  are  located  sufficiently  near  the  surface  of  the  bone  to  give 
rise  to  tender  points,  which  can  be  readily  located  by  finger-pressure. 

3.  Swelling'. — External  swelling  is  absent  until  the  atrophic  layer  of 
compact  bone  yields  to  the  intraosseous  pressure,  as  may  be  seen  in  advanced 
cases  of  spina  ventosa,  or  until  by  pressure  atrophy  over  the  centre  of  the 
focus  the  compact  layer  is  perforated,  and  a  soft,  circumscribed,  boggy  swell- 
ing forms  underneath  the  periosteum.  If  the  granulation-tissue  has  retained 
its  vitality  the  extraosseous  swelling  increases  very  slowly  in  size,  and  there 
is  no  tendency  to  difi:use  infection  of  the  connective  tissue  after  the  granu- 
lations have  reached  the  paraperiosteal  tissues.  Pseudofluctuation  is  gener- 
ally present,  and  many  such  granulating  foci  at  this  stage  have  been  care- 
lessly incised  under  the  mistaken  diagnosis  of  abscess.  If  the  central  focus 
has  undergone  caseation  before  the  periosteum  is  perforated,  then  the  para- 
periosteal tissues  become  rapidly  infected,  and  a  tubercular  abscess,  such  as 
has  been  described  before,  develops  in  a  short  time.  The  abscess  wanders 
away  from  the  place  where  it  originated  in  directions  offering  the  least  re- 
sistance, along  preformed  anatomical  spaces  and  in  obedience  to  the  law  of 
gravitation.  The  size  of  such  an  abscess  is,  absolutely,  no  indication  of  the 
extent  of  the  primary  lesion  in  the  bone,  as  a  minute  focus  may  be  the  cause 
of  a  large  abscess  and  a  small  abscess  may  mark  the  location  of  an  extensive 


562  PEINCIPLES    OF    SURGERY. 

primary  lesion.  (Edema  is  iisually  not  well  marked,  even  if  the  abscess  is 
large,  unless  secondary  infection  with  pyogenic  microbes  has  occurred.  The 
difEuse  form  of  tubercular  osteomyelitis  is  always  attended  by  a  plastic  osteo- 
myelitis, and,  consequently,  the  early  appearance  of  external  swelling  is  one 
of  the  points  to  be  taken  into  consideration  in  differentiating  between  the 
different  forms  of  osteotuberculosis.  The  swelling  that  attends  tuberculosis 
in  bones  deeply  seated — as  the  vertebrae,  hip- joint,  and  pelvic  bones — does 
not  become  apparent  until  the  existence  of  a  tubercular  abscess  indicates  the 
probable  seat  of  the  primary  lesion. 

4.  Redness. — The  skin  over  a  tubercular  focus  in  the  interior  of  a  bone 
or  over  a  tubercular  abscess  presents  a  normal  appearance  until  it  has  be- 
come infected  and  shows  other  unmistakable  signs  of  tuberculosis.  This 
does  not  occur  until  the  granulations  have  permeated  the  deeper  portions  of 
the  skin,  or  until  the  caseous  material  has  only  the  skin  for  its  covering. 
Under  such  circumstances  the  skin  presents  a  dusky-red  hue,  owing  to  im- 
paired capillary  circulation,  and  becomes  more  and  more  attenuated  by 
pressure  atrophy  and  destructive  changes  until  it  finally  yields  to  the  press- 
ure from  beneath,  and  spontaneous  evacuation  of  the  contents  of  the  abscess 
takes  place.  If  the  subcutaneous  product  is  composed  of  granulation-tissue 
the  undermined  skin,  after  perforation  has  taken  place,  is  destroyed  by  de- 
grees and  the  part  presents  the  appearance  of  lupus. 

5.  Atrophy  of  Limb. — Muscular  atrophy  is  almost  a  constant  symptom 
in  osteotuberculosis  as  well  as  in  tubercular  synovitis.  This  atrophy  is  not 
caused  altogether  by  inactivity  of  the  limb,  and  it  appears  to  be  due  in  part, 
at  least,  to  trophoneurotic  lesions. 

Besides  a  careful  study  of  the  clinical  history,  several  diagnostic  meas- 
ures may  be  resorted  to  in  doubtful  cases  to  enable  the  surgeon  to  make  a 
positive  diagnosis. 

Means  of  Differential  Diagnosis. — (a)  Akidopeurastik.— Exploration 
of  a  doubtful  swelling  with  a  strong  steel  needle  was  introduced  by  Mid- 
deldorpf  for  the  purpose  of  ascertaining  the  consistence  and  probable  struct- 
ure of  the  tissues  composing  the  swelling.  He  called  this  simple  procedure 
akidopeurastih.  The  presence  of  a  tubercular  focus  in  the  interior  of  a  bone 
can  often  be  demonstrated  by  this  aid  to  diagnosis  before  any  external  swell- 
ing has  appeared.  A  strong  needle  of  an  hypodermic  syringe  can  be  used 
for  exploring  a  bone  the  density  of  which  has  been  diminished  by  chronic 
inflammation,  if  this  latter  has  not  been  followed  by  osteosclerosis.  During 
the  active  stage  of  osteotuberculosis  the  bone  for  a  considerable  distance 
around  the  focus  is  osteoporotic,  and  can  be  readily  penetrated  by  a  strong, 
sharp  needle.  The  exploration  should  be  made  under  strict  antiseptic  pre- 
cautions. The  puncture  is  made  in  the  centre  of  the  tender  area,  and  in  a 
direction  corresponding  to  the  probable  location  of  the  central  focus.    If  the 


TUBEECULOSIS    OF    BONE.  563 

needle  meet  with  any  considerable  resistance  in  the  bone,  it  is  advanced  by 
rotary  movements;  the  arrival  of  the  point  in  the  granulating  centre  or 
caseous  focus  is  announced  by  a  sudden  loss  of  resistance.  By  advancing 
the  needle  sufficiently  to  touch  the  opposite  side  of  the  cavity  its  probable 
size  can  be  ascertained. 

(b)  Exploratory  Puncture,  with  Aspiration. — If  the  needle  of  an  ex- 
ploratory or  hypodermic  syringe  is  used  to  make  the  akidopeurastik,  explora- 
tion of  the  bone  may  be  followed  by  removing  some  of  the  contents  of  the 
cavity  by  aspiration  for  examination.  If  the  tubercular  product  has  under- 
gone caseation  and  liquefaction  some  of  the  cheesy  material  can  be  removed 
by  aspiration,  and  the  nature  of  the  lesion  may  then  be  revealed  by  positive 
demonstration.  If  still  further  evidence  is  required,  a  guinea-pig  may  be 
inoculated  with  the  same  needle,  which  still  contains  enough  of  the  material 
to  produce  a  positive  result  in  the  animal.  If  the  cavity  contain  granulation- 
tissue  little  fragments  of  this  can  be  drawn  into  the  needle,  and  with  these 
inoculation  experiments  for  diagnostic  purposes  can  be  made.  Search 
for  the  bacillus  tuberculosis  in  the  products  removed  is  a  very  important 
diagnostic  resource.  In  tubercular  necrosis  it  may  be  possible  to  detect 
the  presence  of  the  sequestrum  and  ascertain  its  mobility  by  exploratory 
puncture.  If  a  tubercular  abscess  has  formed,  the  character  of  the  con- 
tents of  the  swelling  may  be  ascertained  by  using  the  exploratory  syr- 
inge, and  the  nature  of  the  primary  cause  demonstrated,  if  need  be,  by 
injecting  the  material  aspirated  into  the  subcutaneous  tissue  or  peri- 
toneal cavity  of  a  guinea-pig.  In  the  differential  diagnosis  of  tubercu- 
losis of  bone,  it  is  necessary  to  exclude  synovial  tuberculosis,  sarcoma, 
echinococcus  cyst,  rachitis,  suppurative  osteomyelitis,  and  syphilis.  Many 
cases  of  primary  tuberculosis  of  bone  have  been  mistaken  for  synovial  tu- 
berculosis, and  vice  versa.  Primary  tuberculosis  of  bone  frequently  results 
in  contractures  of  joints  without  direct  implication  of  the  joint,  and  this  has 
often  led  to  a  wrong  diagnosis.  In  primary  synovial  tuberculosis  the  first 
pathological  changes  occur  in  the  joint,  and  no  tender  points  will  be  found 
in  the  epiphyseal  regions.  In  osteotuberculosis  not  complicated  by  an  ex- 
tension of  the  disease  to  the  adjacent  joint  the  first  symptoms  are  referred 
to  the  lesion  existing  in  the  interior  of  the  bone,  and  it  is  usually  not  diffi- 
cult to  ascertain  the  existence  of  circumscribed  points  of  tenderness  which 
correspond  to  the  location  of  the  foci.  Periosteal  sarcoma  is,  from  the  be- 
ginning, an  extraosseous  product.  Central  sarcoma,  as  a  rule,  increases  more 
rapidly  in  size  than  a  tubercular  swelling,  and  is  often  the  seat  of  pulsations 
and  a  blowing  sound  which  can  be  heard  by  auscultation.  Central  sarcoma 
is  often  the  cause  of  a  pathological  fracture,  while  this  accident  is  exceed- 
ingly rare  in  osteotuberculosis.  Echinococcus  of  bone  is  an  exceedingly  rare 
affection,  but,  as  it  may  simulate  osteotuberculosis,  differential  diagnosis 


564  PRINCIPLES    OF    SURGERY. 

must  be  based  on  an  exploratory  puncture,  which  will  yield  a  clear  serum 
containing  the  characteristic  booklets  in  the  former  instance,  and  granula- 
tion-tissue or  the  products  of  caseous  degeneration  in  the  latter.  Eachitis 
gives  rise  to  swelling  and  pain  in  the  epiphyseal  regions;  but  this  affection 
is  not  limited  to  one  or  two  bones,  and  afEects  almost  every  bone  in  the  body 
alike.  Epiphyseal  multiple  osteomyelitis  is  an  acute  or,  at  least,  subacute 
affection,  and  results  early  in  the  formation  of  purulent  foci,  and  is  often 
attended  by  epiphyseolysis.  The  virus  of  syphilis  has  a  special  predilection 
for  the  periosteum,  while  this  structure  is  almost  immune  to  primary  tuber- 
cular affections.  In  95  out  of  every  100  cases  chronic  inflammation  in  bone 
means  tuberculosis,  and,  unless  there  are  special  reasons  which  should  render 
the  diagnosis  doubtful,  it  is  safe  to  adopt  a  treatment  adapted  for  tubercular 
osteomyelitis  in  almost  every  case  where  the  symptoms  point  to  a  chronic 
inflammation  and  the  existence  of  a  tumor  or  parasitic  growth  can  be  ex- 
cluded. 

Prognosis. — On  the  whole,  the  prognosis  is  more  favorable  in  cases  of 
osteotuberculosis  than  if  the  tubercular  infection  is  located  in  the  skin,  a 
joint,  lymphatic  gland,  or  any  of  the  internal  organs.  Spontaneous  healing 
of  a  tubercular  focus  in  bone  is  possible  under  favorable  conditions.  Every- 
thing that  adds  to  the  patient's  strength  and  power  of  resistance  to  the  mi- 
crobic  infection  adds  to  the  possibility  of  such  a  favorable  termination.  If 
the  patient  is  well  nourished,  and,  above  all,  if  the  blood  is  in  a  normal  con- 
dition, limitation  of  the  disease  may  occur  before  caseation  has  taken  place; 
and  if  cheesy  material  has  formed,  and  it  can  be  removed  by  operative  inter- 
ference, the  prospects  of  a  permanent  recovery  are  good.  It  must  be,  how- 
ever, admitted  that  every  person  who  has  suffered  from  an  attack  of  osteo- 
tuberculosis during  childhood  or  youth,  even  if  an  apparent  perfect  cure  has 
been  effected  spontaneously  or  by  operative  measures,  is  always  in  danger  of 
becoming  the  subject  of  reinfection  at  any  subsequent  time.  The  spores  of 
the  bacillus  of  tuberculosis  may  remain  in  a  latent  condition  for  an  indefinite 
period  of  time  in  the  cicatrized  primary  lesion,  to  become  a  cause  of  subse- 
quent danger  as  soon  as  the  local  or  general  conditions  enable  them  to  ex- 
ercise their  pathogenic  properties.  Healing  by  cicatrization  is  possible  in 
the  small  granulating  foci  so  long  as  the  coagulation-necrosis  is  limited  and 
no  caseation  has  occurred.  In  such  cases  the  embryonal  cells  are  converted 
into  permanent  connective  tissue  and  the  small  fragments  of  bone  are  re- 
moved by  absorption,  while  the  bone  around  the  cicatrix  becomes  sclerosed. 
If  caseation  has  occurred,  but  the  cheesy  material  has  not  undergone  lique- 
faction, capsulation  of  the  tubercular  product  can  take  place  by  the  wall  of 
granulation-tissue  lining  the  cavity  becoming  converted  into  cicatricial  tis- 
sue, forming  a  capsule,  which,  for  the  time  being  at  least,  mechanically  pre- 
vents the  local  extension  of  the  disease.     Small  sequestra  may  become  im- 


TUBERCULOSIS    OF    BONE.  565 

bedded  in  a  connective-tissue  capsule  in  a  similar  manner.  If  the  seques- 
trum is  large  it  will  act  like  every  other  foreign  infected  body,  and  sooner 
or  later  require  an  operation  for  its  extraction.  If  the  tubercular  process  has 
extended  to  a  joint,  the  prognosis  is  more  grave,  and  the  chances  for  a  spon- 
taneous recovery  are  much  diminished.  The  prognosis  is  always  more  grave, 
other  things  being  equal,  if  the  bone  affected  is  so  located  that  removal  of 
the  primary  focus  by  operative  treatment  is  anatomically  impossible.  The 
danger  to  life  and  the  probability  of  local  extension  are  always  greater  if  the 
granulation-tissue  has  been  destroyed  by  coagulation-necrosis  and  caseation, 
as  the  granulation-tissue  is  one  of  the  means  by  which  regional  and  general 
infection  are  retarded  or  prevented.  The  danger  to  life  is  imminent  if  a  large 
tubercular  abscess  has  become  infected  with  pus-microbes,  as  the  secondary 
infection  results  in  destruction  of  the  granulation-tissue  lining  the  cavity, 
which  favors  the  local  and  general  extension  of  the  tubercular  infection,  and 
at  the  same  time  brings  sepsis,  exhaustion  from  profuse  suppuration,  and 
amyloid  degeneration  of  important  internal  organs  as  additional  elements  of 
danger.  The  prognosis  is  alwaj^s  more  grave  in  persons-  advanced  in  years 
than  in  children,  as  limitation  of  the  disease  occurs  more  frequently  in  the 
latter. 

Treatment. — The  medical  treatment  in  patients  suffering  from  osteo- 
tuberculosis  must  be  tonic  and  supporting.  Dietetic  and  hygienic  treatment 
is  of  more  value  than  the  administration  of  drugs.  Sea-bathing  and  change 
of  climate  will  often  accomplish  more  than  bitter  tonics,  iron,  quinine,  ar- 
senic, and  codliver-oil.  The  prolonged  internal  administration  of  guaiacol 
pr  one  of  its  preparations  should  always  be  resorted  to.  The  local  treat- 
ment, short  of  a  radical  operation,  must  consist  in  the  use  of  such  means  as 
will  aid  the  natural  resources  in  effecting  limitation  of  the  tubercular  proc- 
ess, of  which  the  most  important  is 

1.  Physiological  Rest. — The  importance  of  securing  for  the  inflamed 
part,  as  near  as  can  be  done  by  mechanical  support,  absolute  physiological 
rest  cannot  be  overestimated.  The  process  of  repair  in  a  tubercular  focus 
often  meets  with  great  and  insurmountable  difficulties.  The  embryonal  cells, 
of  low  vitality  almost  from  the  beginning,  are  poisoned  as  soon  as  born  with 
the  toxins  of  the  bacillus  of  tuberculosis,  and  consequently  are  converted 
into  tissue  of  a  higher  type  only  under  the  most  favorable  conditions.  The 
non- vascularity  of  tubercle-tissue  is  another  cause  why  the  inflammatory 
product  so  seldom  takes  an  active  part  in  the  process  of  repair.  The  first 
indication  in  the  treatment  of  a  tubercular  osteomyelitis  is  to  secure  for  the 
part  a  favorable  condition  of  the  circulation,  which  can  only  be  done  by 
securing  rest.  The  most  efficient  way  to  procure  rest,  not  only  for  the  dis- 
eased part,  but  for  the  entire  body,  is  to  confine  the  patient  to  bed;  but,  as 
these  affections  are  noted  for  their  chronicity,  lasting  for  months  and  years. 


566  PRINCIPLES    OF    SUEGERY. 

enforced  rest  by  this  method  would  seriously  impair  the  general  health,  and 
on  this  account  it  is  advisable,  in  the  majority  of  cases,  to  resort  to  one  of 
the  numerous  mechanical  appliances  which  will  immobilize  the  part;  while, 
at  the  same  time,  the  patient  can  avail  himself  of  the  benefits  to  be  derived 
from  out-door  air  and  change  of  scenery  and  surroundings. 

In  tuberculosis  of  the  spine  the  most  efficient  treatment  during  the 
acute  stage  is  the  dorsal  recumbent  position  upon  a  Eauchfuss  sling,  fol- 
lowed by  Sayre^s  plaster-of-Paris  jacket,  applied  while  the  patient  is  partly 
suspended,  which  answers  a  more  useful  purpose  than  any  of  the  numerous 
complicated  apparatuses  which  have  been  as  yet  devised.  To  apply  the  jacket 
properly  requires  a  great  deal  of  experience  and  the  exercise  of  considerable 
skill.  In  many  communities  this  method  of  treatment  has  become  un- 
popular, both  among  physicians  and  the  laity,  from  the  bad  results  caused 
by  improper  applications  of  the  jacket.  Hyperextension  must  be  avoided, 
and  the  patient  must  be  instructed  to  extend  himself  only  until  pain  is  re- 
lieved and  not  beyond  this  point.  The  bony  prominence  at  the  seat  of  curva- 
ture must  be  carefully  protected  against  pressure  by  applying  on  each  side 
a  firm  pad  sufficiently  thick  to  prevent  contact  of  the  projecting  spinous 
processes  with  the  plaster  cast.  The  plaster  bandages  themselves  must  be 
applied  smoothly,  so  that  after  extension  is  removed  the  jacket  will  closely 
fit  the  unequal  surface  of  the  body.  Another  matter  of  great  importance 
is  to  see  the  patient  from  time  to  time,  in  order  to  determine  whether  the 
jacket  causes  injurious  pressure  at  any  point,  which,  if  this  should  be  the 
case,  is  remedied  at  once,  either  by  cutting  out  that  portion  of  the  jacket 
which  has  caused  the  decubitus  or  by  applying  a  new  one.  In  tuberculosis 
of  any  of  the  bones  of  the  extremities  rest  can  be  secured  most  efficiently  by 
immobilizing  the  limb  in  a  plaster-of-Paris  dressing.  The  splint  must  always 
include  one  or  more  of  the  adjacent  joints.  Undue  constriction  of  the  limb 
is  prevented  by  interposing  between  it  and  the  splint  a  thin  layer  of  salic- 
ylized  cotton.  If  the  disease  affect  any  of  the  bones  of  the  lower  extremities 
the  patient  must  not  be  allowed  to  walk  without  crutches. 

2.  Ignipuncture. — During  the  early  stages  of  osteotuberculosis  excel- 
lent results  have  been  obtained  by  ignipuncture:  a  method  of  treatment 
devised  by  Eichet  in  1870.  If  a  tubercular  focus  can  be  accurately  located, 
this  method  of  treatment  should  receive  a  trial,  as  it  is  not  attended  by  any 
risks  and  frequentlj^  effects  a  permanent  cure.  The  field  of  operation  is  thor- 
oughly disinfected,  and,  with  the  needle-point  of  a  Paquelin  cautery  heated 
to  a  dull  red  heat,  the  soft  tissues  and  bone  are  perforated.  In  making 
the  perforation  it  is  necessary  to  advance  the  point  slowly  and  to  remove  it 
from  time  to  time  and  revive  the  heat  in  order  to  prevent  impaction  of  the 
point.  The  entrance  of  the  point  of  the  instrument  into  the  cavity  or  tuber- 
cular focus  can  be  readily  felt,  as  resistance  at  that  moment  is  suddenly 


TUBEECULOSIS    OF    BONE.  567 

diminished.  The  therapeutic  effect  of  ignipuncture  is  threefold:  1.  The 
tunnel  made  establishes  free  drainage  and  relieves  promptly  the  intraosseous 
tension.  2.  At  least  a  portion  of  the  infected  tissue  is  destroyed  by  the  heat. 
3.  A  plastic  osteomyelitis  is  excited  in  the  vicinity  of  the  track  and  in  the 
cauterized  portion  of  the  cavity^  which  exerts  a  favorable  influence  in  bring- 
ing about  limitation  of  the  disease,  or  even  in  effecting  a  final  cure.  Through 
the  opening  made  iodoform  can  be  introduced  into  the  cavity,  which  offers 
additional  advantage  in  treating  osseous  foci  successfully  by  this  procedure. 
To  insure  a  successful  issue  it  is  absolutely  necessary  to  prevent  infection  with 
pus-microhes  through  the  openimg  ty  mahing  the  operation  under  strict 
aseptic  precautions,  and  protecting  the  puncture  with  an  efficient  antiseptic  ab- 
sorhent  dressing  until  it  is  completely  closed  by  cicatrization  and  epidermiza- 
tion.  Ignipuncture  is  most  useful  in  the  treatment  of  accessible  foci  in  the 
epiphyseal  extremities  of  the  long  bones  and  during  the  early  stages  of 
tuberculosis  of  the  wrist  and  tarsus.  In  incipient  tuberculosis  of  the  tarsus 
I  have  repeatedly  obtained  a  satisfactory  and  permanent  result  by  making 
an  opening  through  the  entire  tarsus  from  side  to  side,  in  a  line  of  the  dis- 
ease, by  inserting  the  point  from  each  side,  the  two  tunnels  meeting  in  the 
centre.  Ignipuncture  always  relieves  the  pain  promptly,  and  the  track  made 
is  completely  closed  by  permanent  tissue  in  the  course  of  a  few  weeks. 

Parenchymatous  Injections  of  lodoforni. — In  foci  accessible  to  punct- 
ure parenchymatous  injections  of  a  10-per-oent.  iodoform-glycerin  emulsion 
deserve  a  faithful  trial.  This  method  of  treatment  is  of  special  value  in  cases 
in  which  the  bone  affection  has  resulted  in  the  formation  of  a  tubercular 
abscess.  In  such  instances  not  only  the  abscess-cavity,  but  the  tissues  at  the 
primary  focus,  should  be  iodoformized. 

3.  Radical  Operation. — (a)  Removal  of  Limited  Foci. — The  radical 
treatment  of  tuberculosis  of  bone  consists  in  the  complete  removal  of  the 
infected  tissues  by  operative  interference.  The  success  which  follows  this 
treatment  is  most  marked  in  cases  where  caseation  has  not  taken  place, — - 
that  is,  in  the  granulating  form, — and  in  other  forms  where  the  operation  is 
performed  before  extensive  secondary  pathological  conditions  have  occurred. 
The  operation  is  indicated  as  soon  as  a  positive  diagnosis  can  be  made,  and 
after  the  milder  measures  have  proved  useless  in  arresting  the  progress  of 
the  disease.  Timely  surgical  interference  in  osteotuberculosis  is  not  only 
calculated  to  become  the  surest  means  of  preventing  general  infection,  but 
it  also  has  for  its  object  the  limitation  of  the  disease  by  the  removal  of  the 
primary  cause,  and  by  accomplishing  these  objects  it  becomes  at  once  a 
prophylactic  as  well  as  a  curative  measure.  If  a  tubercular  focus  or  foci  can 
be  removed  by  a  radical  operation  before  the  adjacent  joint  has  become  in- 
fected, then  the  operation  has  not  only  been  successful  in  effecting  a  per- 
manent cure,  but  it  has  also  been  instrumental  in  preventing  the  extension 


568  PEINCIPLES    OF    SUEGERY. 

of  the  disease  to  the  joint.  If  the  operation  is  undertaken  at  a  time,  as  it 
should  be,  before  any  external  swelling  has  appeared,  the  surgeon  must  be 
guided  in  finding  the  focus  by  searching  for  tender  points,  aided,  if  neces- 
sary, by  exploratory  punctures.  As  in  epiphyseal  tuberculosis  the  foci  are 
always  near  a  joint,  the  incision  for  exposing  the  bone  should  be  made  in 
such  a  manner  as  to  avoid  opening  the  joint.  A  case  of  central  tuberculosis 
of  the  neck  of  the  femur,  as  shown  in  Fig.  191,  was  subjected  to  a  successful 
extraarticular  operation  by  Volkmann.  If  the  focus  be  so  close  to  the  joint 
as  to  make  it  necessary  to  remove  bone  underneath  the  insertion  of  the  cap- 
sule or  ligaments  of  the  joint,  it  is  advisable  to  lift  the  periosteum  with  the 
joint-structures  from  the  bone  to  some  distance  from  the  incision,  and  in  this 
manner  avoid  injury  to  the  joint.  The  bone  overlying  a  tubercular  focus  or 
abscess  is  usually  softened  and  easily  removed  with  a  small,  hollow  chisel. 
The  limb  should  always  be  rendered  bloodless  by  using  Esmarch's  con- 


Fig.  191. — Central  Tuberculosis  of  the  Neck  of  tlie  Femur.    {Volkmann.) 

stricter,  so  that  the  operator  can  identify  the  tissues  as  they  are  being  re- 
moved during  the  operation.  If,  after  tunneling  the  bone  for  a  considerable 
distance,  the  focus  be  not  found,  it  is  advisable  to  make  from  this  track 
exploratory  punctures  in  different  directions  with  a  small  perforator  until 
the  cavity  is  found,  which  is  then  freely  exposed  with  the  chisel.  As  soon 
as  this  has  been  done  the  sharp  spoon  is  used,  with  which  the  necrosed  bone, 
granulation-tissue,  or  cheesy  material  is  removed.  The  osteoporotic  bone  in 
the  immediate  vicinity  of  the  cavity  is  removed  in  a  similar  manner,  and  the 
surgeon  must  assure  himself,  by  repeated  examinations  of  the  tissue  re- 
moved, that  healthy  tissue  has  been  reached  before  the  sharp  spoon  is  laid 
aside. 

If  any  doubt  remain  whether  all  of  the  infected  tissue  has  been  re- 
moved, it  is  better  to  resort  to  ignipuncture,  perforating  the  bone  at  different 
points  to  the  depth  of  a  few  lines  with  the  sharp  point  of  a  Paquelin  cautery 


TUBEECULOSIS    OF    JOINTS.  569 

in  addition  to  the  curetting.  This  procedure  will  destroy  at  least  some  of 
the  bacilli  which  might  have  remained^  and  will  incite  a  plastic  osteomye- 
litis that  will  effectually  resist  the  pathogenic  action  of  such  microbes  that 
still  remain.  After  the  cavity  has  been  thoroughly  irrigated  with  an  anti- 
septic solution  it  is  dried,  iodoformized,  and  packed  with  antiseptic  decalci- 
fied bone-chips.  The  periosteum  is  separately  sutured  over  the  bone-pack- 
ing, sufficient  space  being  left  to  insert,  at  the  lower  angle  of  the  wound,  a 
few  threads  of  catgut  to  serve  as  a  capillary  drain.  The  remaining  tissues 
are  included  in  the  superficial  sutures  and  an  antiseptic  dressing  applied. 
The  limb  must  be  immobilized  by  applying  a  well-padded  posterior  splint. 
If  all  the  infected  tissues  have  been  removed  and  no  infection  with  pus- 
microbes  have  taken  place  during  or  after  the  operation,  the  wound  unites 
under  one  dressing  in  from  one  to  two  weeks,  and  the  definitive  healing  of 
the  cavity  is  completed  in  the  course  of  three  to  six  weeks,  according  to  the 
condition  and  age  of  the  patient  and  the  size  of  the  cavity.  The  packing  of 
such  cavities  with  iodoformized  decalcified  bone-chips  is  an  important  ele- 
ment in  the  prevention  of  a  local  recurrence  and  general  infection,  and  in 
securing  satisfactory  healing  of  the  wound  and  complete  restoration  of  the 
lost  parts.  Should  suppuration  follow  the  operation,  secondary  implanta- 
tion with  decalcified  bone-chips  can  be  done  successfully  as  soon  as  suppura- 
tion has  ceased,  and  the  cavity  can  be  made  thoroughly  aseptic. 

(b)  Excision  of  Portion  of  Shaft. — This  operation  is  only  indicated  in 
some  cases  of  diffuse  tubercular  osteomyelitis  where  amputation  is  consid- 
ered unnecessary.  Eesection  of  the  entire  thickness  of  the  shaft  of  a  long 
bone  for  tuberculosis  should  be  limited  to  the  radius,  ulna,  fibula,  tibia,  the 
metatarsal  and  the  metacarpal  bones.  Extirpation  of  the  entire  bone  affected 
is  frequently  necessary  in  tuberculosis  of  the  wrist-  and  ankle-  joints. 

(c)  Amputation. — Amputation  is  often  the  only  choice  in  the  treat- 
ment of  diffuse  tubercular  osteomyelitis,  as  it  offers  the  only  chance  to  effect 
complete  eradication  of  the  disease,  and  to  protect  the  patient  against  general 
infection.  It  is  contraindicated  in  the  other  forms  of  osteotliberculosis, 
unless  complicated  by  tuberculosis  of  an  adjacent  joint,  and  even  in  such 
instances  it  is  limited  to  cases  that  have  passed  beyond  the  reach  of  a  typical 
or  atypical  resection. 

TUBERCULOSIS    OF   JOINTS. 

Tuberculosis  of  joints,  chronic  fungous  arthritis,  strumous  arthritis, 
and  tumor  albus  are  terms  that  even  now  are  being  used  synonymously  to 
indicate  a  form  of  inflammation  of  joints  which  clinically  is  characterized 
by  its  chronic  course  and  the  absence  of  acute  signs  of  inflammation.  This 
affection  is  by  far  the  most  common  joint  disease,  so  much  so  that  Konig 
states  that  in  surgical  clinics  the  surgeon  will  have  100  cases  of  tuberculosis 


570  PEINCIPLES    OF    SURGEKY. 

of  the  joints  to  deal  with  to  one  of  the  other  classes  of  inflammation,  such 
as  gonorrhoeal,  syphilitic,  suppurative,  osteomyelitic,  rheumatic,  or  the  meta- 
static inflammations  subsequent  to  acute  infectious  diseases. 

Etiology. — We  distinguish,  as  to  origin,  between  primary  synovial  and 
primary  osteal  tuberculosis  of  the  joints.  If  the  primary  focus  is  in  the 
bone  the  disease  usually  extends  to  the  joint  by  direct  progression  of  the 
process  to  the  structure  of  the  joint.  In  primary  synovial  tuberculosis  the 
bacillus  is  conveyed  through  the  circulation,  and  localization  takes  place  in 
the  synovial  membrane. 

Max  Schliller  proved  experimentally,  in  animals  infected  with  tubercle 
bacilli, — for  instance,  through  the  respiratory  tract, — that  a  slight  trau- 
matism to  a  joint  would  determine  localization,  by  way  of  the  circulation, 
to  the  injured  part,  and  that  a  tubercular  synovitis  or  panarthritis  would 
follow.  The  same  author  makes  the  statement,  based  on  the  results  of  his 
experiments,  that  a  slight  injury  to  a  joint  in  a  person  who  has  bacilli  float- 
ing in  his  blood  would  determine  localization,  commonly  in  the  form  of  a 
synovial  tuberculosis.  Clinically,  tuberculosis  of  joints  has  been  traced  in 
56  per  cent,  of  the  cases  to  traumatism  by  a  direct  blow  to  a  joint,  or  dis- 
tortion, or  overexertion.  It  is  characteristic  that  the  traumatism  is  always 
slight;  a  severe  injury,  causing  intraarticular  fracture,  is  very  rarely  fol- 
lowed by  tuberculosis,  for  the  same  reasons  that  severe  injuries  do  not  pro- 
duce the  disease  in  bone  and  other  organs.  It  may  be  stated  that,  as  to  the 
relative  frequency  of  the  two  forms  of  infection,  it  has  been  shown  that  pri- 
mary osteal  tuberculosis  occurs  two  or  three  times  as  often  as  the  primary 
synovial.  Tuberculosis  of  joints  is  always  closely  related  to  the  same  disease 
in  bone,  because,  when  it  does  not  follow  the  latter  as  a  secondary  lesion, 
the  primary  synovial  disease  not  seldom  implicates  the  adjacent  bone  from 
direct  extension  of  the  infection  from  the  fungous  synovial  membrane 
to  the  subjacent  bone  structure.  Synovial  tuberculosis  is  more  frequent  in 
the  adult  than  in  children.  Primary  infection  of  a  joint  is  possible  only 
through  a  wound,  as  in  the  case  referred  to  under  the  head  of  "Inoculation- 
tuberculosis."  Tubercular  infection  of  an  intact  joint  presupposes  the  en- 
trance of  the  bacillus  of  tuberculosis  through  the  respiratory  tract  or  ali- 
mentary canal,  or  through  some  external  infection-atrium  into  the  systemic 
circulation,  or  the  diffusion  of  bacilli  through  the  same  channel  from  some 
preexisting  tubercular  focus,  and  the  localization  of  floating  bacilli  in  the 
synovial  membrane  by  capillary  embolism  or  by  mural  implantation.  A 
simple  tubercular  nodule  over  the  surface  of  the  synovial  membrane  may 
lead,  in  a  comparatively  short  time,  to  diffuse  tuberculosis  over  the  entire 
surface  of  the  joint  by  local  dissemination  of  the  microbes,  in  which  the 
synovial  fluid  and  the  movements  of  the  joint  play  an  important  part.  In 
the  osteal  form  of  tuberculosis  of  joints  the  infection  extends  from  the  bone 


TUBERCULOSIS    OF    JOINTS.  571 

to  the  joint  at  once,  in  cases  where  the  primary  disease  is  the  result  of  in- 
farction, as  the  base  of  the  wedge-shaped  piece  of  the  necrosed  bone  com- 
municates directly  with  the  joint;  while  infection  of  the  joint  occurs  sec- 
ondarily, in  cases  of  granulating  foci  and  tubercular  necrosis,  by  perforation 
of  the  tubercular  product  into  the  joint.  When  the  foci  are  located  close  to 
the  articular  cartilage  this  must  be  destroyed  before  the  joint  is  invaded, 
the  cartilage  forming  a  barrier  that  may  sometimes  prove  sufficient  to  resist 
invasion.  In  case  a  focus  is  located  at  the  surface  of  a  joint,  where  the  bone 
is  not  covered  with  articular  cartilage,  the  thin  periosteum  and  the  synovial 
membrane  covering  it  are  more  easily  perforated,  and  consequently  second- 
ary synovial  tuberculosis  is  more  liable  to  follow.  The  most  complicating 
condition  may  arise  if  a  tubercular  focus  is  located  at  the  insertion  of  the 
capsule  of  a  joint.     It  may  then  open  into  and  outside  of  the  joint  simul- 


Fig.  192.— Tuberculosis  cf  Lower  Epiphysis  of  Femur,  with  Two  Sequestra  (a,  a) 
and  Perforation  into  Knee-joint.     (Weher.) 

taneously,  or  the  one  or  the  other,  the  integrity  of  the  joint  depending  on 
the  few  lines  of  space  occupied  by  the  capsule. 

Pathology  and  Morbid  Anatomy.— In  synovial  tuberculosis  a  series  of 
pathological  changes  are  initiated  in  which  all  the  structures  of  the  joint 
are  finally  concerned,  namely:  the  synovial  membrane,  parasynovial  tissues, 
articular  cartilage,  and  lastly  the  bone.  The  tubercle-nodule  in  the  synovial 
membrane  presents,  under  the  microscope,  the  same  histological  structure  as 
in  other  tissues.  When  the  synovial  surface  has  become  the  seat  of  diffuse 
tuberculosis  the  tissues  undergo  the  same  pathological  changes  as  during  the 
first  stage  of  tuberculosis  in  other  organs,  and  it  is  the  characteristic  granu- 
lation-tissue that  has  given  to  this  form  of  arthritis  the  names  of  fungous 
synovitis  and  synovitis  hyperplastica  granulosa.  During  the  early  stages  of 
the  disease  the  surgeon  meets  with  two  distinct  varieties;   in  one  the  tuber- 


578  PEiNCiPLES  or  sukgeky. 

cular  infection  produces  a  pnlpy  condition  of  the  entire  synovial  sac,  with 
little  or  no  effusion  into  the  joint,  the  swelling  being  due  entirely  to  the 
presence  of  a  thick  layer  of  granulation-tissue:  the  true  tumor  alius  of  the 
old  writers.  This  form  of  tuberculosis  gives  rise,  at  an  early  stage,  to  ex- 
tensive deformity  of  the  joint,  flexion,  rotation,  and,  in  the  case  of  the  knee- 
joint,  partial  dislocation  of  the  tibia  backward.  In  the  other  variety  the 
fungous  granulations  are  less  marked,  but  a  copious  effusion  takes  place  into 
the  joint,  which  simulates  a  catarrhal  synovitis,  until  time  and  the  effect  of 
treatment  enable  the  surgeon  to  make  a  correct  differential  diagnosis.  In 
this  form  Konig  assures  us  that  he  has  never  observed  a  tendency  to  flexion 
or  any  other  form  of  displacement  of  the  joint-surfaces.  If  suppuration  take 
place,  which  is  not  very  often  the  case,  it  begins  in  the  granulations  which 
cover  the  synovial  membrane,  and  the  pus  accumulates  in  the  cavity  of  the 
joint  until  perforation  of  the  capsule  takes  place.  During  the  suppurating 
process  the  granulations  are  destroyed  and  the  tubercular  infection  pene- 
trates deeper,  and,  as  during  the  destructive  process  blood-vessels  are  de- 
stroyed, the  patient  is  exposed  to  the  additional  risks  of  general  infection. 
If  a  tubercular  joint  open  spontaneously,  or  is  incised  Avithout  observing 
strict  aseptic  precautions,  the  additional  infection  from  without  leads  to 
the  most  serious  consequences,  as  under  these  circumstances  pus-microbes 
are  brought  in  contact  with  a  surface  that  has  been  admirably  prepared  by 
the  bacillus  of  tuberculosis  for  suppurative  and  septic  processes. 

Patholog'ical  Varieties  of  Joint  Tuberculosis. — Tubercular  inflammation 
of  the  synovial  membrane  of  joints  results  in  different  gross  pathological 
conditions  that  serve  as  a  basis  for  classification  into:  1.  Pannous  hyper- 
plastic synovitis.  2.  Tuberous  hyperplastic  synovitis  or  papillomatous  plas- 
tic synovitis.  3.  Granu.lar  or  fungous  hyperplastic  synovitis.  4.  Tubercular 
articular  empyema. 

1.  Pannous  Hyperplastic  Synovitis.  —  The  tubercle-nodules  are  ex- 
tremely small,  rarely  visible  to  the  naked  eye,  and  widely  disseminated  over 
the  entire  or  greater  portion  of  the  synovial  sac.  The  synovial  membrane  is 
only  moderately  thickened,  but  quite  vascular.  From  the  border  of  the  carti- 
lage a  thin,  vascular  layer  of  granulations  approaches  the  centre  of  the  sur- 
face of  the  joint  somewhat  in  the  manner  a  pannus  invades  the  cornea.  This 
form  of  sj'^novitis  was  first  described  by  Hueter. 

2.  Tubercular  Plastic  Synovitis  or  Papillomatous  Plastic  Synovitis. — 
The  tubercular  inflammation  results  in  the  formation  of  subs3aiovial  fibrous 
masses,  which  may  attain  the  size  of  a  walnut,  protruding  into  the  joint  and 
filling,  for  example,  the  suprapatellar  recess  of  the  knee-joint,  with  simple 
irritative  synovitis  or  pannous  synovitis  in  the  rest  of  the  cavity.  The  tuber- 
cular infection  in  such  cases  is  limited,  and  the  removal  of  the  fibrous  swell- 
ing results  in  a  permanent  cure.    In  other  cases  of  the  same  t3^pe  of  inflam- 


TUBERCULOSIS    OF    JOINTS.  573 

mation  the  foci  are  numerous,  resulting  in  papillomatous  plastic  synovitis, 
where  the  whole  inner  surface  of  the  synovial  membrane  is  covered  with 
sessile  or  pedunculated  papillomatous  growths,  small  and  rather  uniform  in 
size,  some  of  which  may  become  detached,  when  they  constitute  the  so-called 
rice-bodies. 

3.  Granular  Fungous  Hyperplastic  Synovitis. — In  this  variety  of  joint 
tuberculosis  the  synovial  membrane  is  affected  throughout,  being  consid- 
erably thickened  and  hypergemic,  and  covered  by  a  more  or  less  thick  layer 
of  velvety  granulations.  The  ligaments  and  paraarticular  structures  are 
affected  at  a  comparatively  early  stage,  and  thus  is  formed  the  thick,  oedema- 
tous  mass  of  tissue,  usually  of  a  gelatinous  appearance,  in  which  here  and 
there  cheesy  foci  are  found. 

Any  of  the  foregoing  forms  of  tubercular  synovitis  may  give  rise  to  the 
transudation  of  serum  or  a  sero-fibrinous  fluid  into  the  joint:  the  tuber- 
cular hydrops  of  Konig.  As  a  rule,  the  serous  effusion  is  most  copious  in 
cases  where  the  synovial  membrane  has  undergone  the  least  change;  that  is, 
in  pannous  hyperplastic  synovitis.  In  tuberous  and  papillomatous  synovitis 
the  effusion  is  usually  scanty,  and  in  fungous  synovitis  attended  by  the  for- 
mation of  massive  granulations  it  is  absent,  as  a  rule.  The  effusion  into  the 
joint,  in  tubercular  hydrops,  is  either  a  thin,  clear  synovia,  or  it  is  rendered 
slightly  turbid  from  the  admixture  of  leucocytes  and  the  products  of  coagu- 
lation-necrosis, or,  if  the  effusion  is  of  a  sero-fibrinous  character,  it  contains 
shreds  of  fibrin.  The  rice-bodies  {corpora  amylacece),  so  frequently  found  in 
tubercular  joints,  are  composed  of  soft  masses  of  fibrin  or  they  are  detached 
papillomata.  That  these  bodies  are  a  tubercular  product  I  have  repeatedly 
satisfied  myself  by  inoculation  experiments. 

4.  Tubercular  Articular  Empyema  (Komg). — The  tubercular  abscess  of 
joints  is  an  advanced  stage  of  the  other  varieties  of  tubercular  synovitis.  The 
inside  of  the  capsule  is  covered  with  a  loosely  adherent  tuberculous  mem- 
brane, similar  to  that  in  tubercular  abscesses.  The  superficial  granulations 
which  compose  this  membrane  have  undergone  degenerative  changes.  Out- 
side of  this  membrane  the  tissues  are  diffusely  infiltrated  with  miliary 
tubercles,  but  the  infection  does  not  extend  beyond  the  synovial  membrane. 
The  fluid  in  the  joint,  like  in  all  tubercular  abscesses,  is  not  pus,  but  serum, 
in  which  we  find  suspended  the  products  of  coagulation-necrosis.  With  the 
extension  of  the  tubercular  process  beyond  the  limits  of  the  synovial  sac, 
the  articular  cartilage  and,  finally,  the  bone  are  successively  attacked.  The 
articular  cartilage  takes  no  active  part  in  the  inflammatory  process;  it  is 
detached  and  removed  by  the  granulations.  An  osseous  focus  in  contact  with 
the  cartilage  usually  makes  a  circular  defect  through  which  the  granulations 
or  cheesy  material  can  be  seen.  The  cartilage  covering  a  tubercular  infarct 
is  rapidly  destroyed,  and  is  mechanically  detached  in  smaller  or  larger  frag- 


574 


PEINCIPLES    OF    SURGEEY. 


ments.  In  primary  tuberculosis  of  the  synovial  membrane  the  process  usu- 
ally commences  at  the  periphery  of  the  articular  cartilage,  and  from  here 
the  granulations  dip  down  into  the  vascular  bone,  and  often  undermines 
the  cartilage  extensively  before  any  destructive  changes  are  witnessed  on 
the  side  directed  toward  the  joint.  In  such  cases  the  cartilage  is  not  only 
often  extensively  detached,  but  perforated  at  numerous  points  by  the  granu- 
lations underneath  it.  The  action  of  the  granulations  on  the  articular  ex- 
tremities of  the  bone  produces  a  condition  which  has  been  described  for 
centuries  as  caries.  Caries  is  not  a  disease,  but  the  result  of  a  disease.  The 
bone  is  softened,  and  by  molecular  disintegration,  caused  by  action  of  the 
granulations,   it   becomes  porous  and   honey-combed.      Numerous   miliary 


Fig.  193. — Tubercular  Empyema  of  Knee-joint. 


nodules  can  be  seen  in  the  affected  area,  which,  in  the  course  of  time,  un- 
dergo coagulation-necrosis  and  caseation.  In  long-standing  cases  the  de- 
struction of  bone  is  so  extensive  that  in  the  hip- joint,  for  instance,  it  may 
result  in  the  loss  of  the  entire  head  of  the  femur  and  perforation  of  the 
acetabulum. 

Symptoms  and  Diagnosis. — The  symptoms  vary  according  to  the  type 
of  the  disease  and  manner  of  infection.  With  the  exception  of  circumscribed 
points  of  tenderness  outside  of  the  region  of  the  joint  that  indicate  the  ex- 
istence of  primary  osteotuberculosis,  we  have  no  symptoms  which  enable  us 
to  make  a  positive  diagnosis  between  a  primary  osteal  and  a  primary  synovial 
tuberculosis  of  a  joint.  The  primary  osteal  form  is  the  most  common.  In 
the  knee  the  proportion  of  the  primary  osteal  to  the  primary  synovial  form 


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t. 

TUBEECULOSIS    OF    JOINTS.  575 

is  in  the  proportion  of  3  to  1;  in  the  hip,  4  to  1;  in  the  elbow,  4  to  1.  As 
to  age,  the  proportion  is,  in  children  below  15  years  of  age,  2  to  1;  above 
15,  3  to  1.  In  reference  to  the  location  of  the  joints  affected,  it  can  be  said 
that  joint  tuberculosis  is  much  more  frequent  in  the  lower  than  in  the  upper 
extremities.  According  to  Albrecht,  out  of  325  cases,  in  91  the  disease 
affected  the  joints  of  the  upper  and  in  234  those  of  the  lower  extremities. 
1.  Swelling. — In  the  atrophic  form  of  plastic  synovitis — the  caries 
sicca  of  Volkmann,  so  common  in  the  shoulder- joint — there  is  not  only  no 
swelling,  but  the  region  of  the  joint  may  even  be  found  atrophied  from  mus- 
cular atrophy.  The  absence  of  swelling  and  the  presence  of  considerable 
mobility  in  the  joint  may  lead  to  a  wrong  diagnosis  under  the  impression 
that  the  affection  is  a  neurosis.  A  careful  examination  under  the  influence 
of  an  anaesthetic  will,  however,  reveal  restriction  of  mobility  from  cicatricial 
contraction  of  the  tubercular  capsule*  which  will  enable  the  surgeon  to  make 
an  early  and  correct  diagnosis.  The  swelling  resulting  from  tubercular  hy- 
drops and  abscess  is  caused  exclusively  by  distension  of  the  capsule  with  fluid, 
as  the  capsule  in  either  case  is  but  little  thickened  and  the  granulations  are 
scanty.  In  both  of  these  conditions  the  capsule  of  the  joint  is  often  enor- 
mously distended.  In  the  knee-joint  the  patella  is  raised  from  the  condyles 
of  the  femur,  and  the  depression  on  each  side  of  it,  present  in  a  normal  con- 
dition in  the  extended  position  of  the  limb,  is  not  only  effaced,  but  replaced 
by  a  well-marked  prominence.  Fluctuation  is  distinct.  In  the  dry,  fungous 
variety  of  synovitis  the  swelling  is  due  to  the  masses  of  granulation-tissue 
within,  and,  after  perforation  of  the  capsule  has  occurred,  within  and  outside 
of  the  joint.  This  is  the  most  common  of  all  the  forms  of  articular  tuber- 
culosis. The  old  authors  were  of  the  opinion  that  the  oedema  in  the  neigh- 
borhood of  a  white  swelling  was  due  to  expansion  or  enlargement  of  the 
articular  extremities  of  the  bones,  until  Samuel  Cooper  pointed  out  that  it 
was  caused  by  thickening  of  the  capsule.  The  granulation-tissue  is  often 
present  in  such  abundance  as  to  give  rise  to  considerable  distension  of  the 
joint,  and,  in  the  knee-joint,  elevating  the  patella  from  the  condyles  of  the 
femur  to  such  an  extent  that  the  contour  of  the  joint  simulates  an  effusion 
into  that  articulation.  The  granulations  are  so  soft  that  on  palpation  in 
these  cases  fluctuation  can  be  distinctly  felt,  especially  if  the  capsule  of  the 
joint  is  very  thin  from  overdistension  or  destructive  changes.  To  ascertain 
the  character  of  the  contents  of  such  a  joint  it  is  usually  necessary  to  resort 
to  an  exploratory  puncture.  The  invasion  of  the  paraarticular  tissues  causes 
considerable  swelling  in  the  region  of  the  joint,  imparting  to  the  latter  the 
characteristic  spindle  shape  so  frequently  found  in  the  knee-,  elbow-,  and 
ankle-  joints,  the  swelling  being  so  much  the  more  conspicuous  when  atrophy 
of  the  muscles  above  and  below  has  taken  place.  Extension  of  the  infiltra- 
tion from  the  paraarticular  tissues  in  the  direction  of  the  subcutaneous  tis- 


576 


PEINCIPLES    OF    SUEGERY. 


sues  finally  causes  the  swollen  joint  to  be  covered  with  a  whitish,  immovable, 
dense  skin,  giving  the  joint  the  appearance  from  which  the  time-honored 
name  of  white  siuelUwg  was  derived.  If  a  periarticular  abscess  appear  the 
swelling  of  the  joint  is  generally  diminished,  while  a  new  swelling  forms  in 
the  vicinity  or  some  distance  from  the  joint. 

2.  Pain. — Pain,  as  a  symptom  accompanying  tuberculosis  of  joints,  al- 
though always  present,  is  of  extremely  variable  intensity.  In  some  cases  it 
is  so  slight  that  patients  will  continue  to  use  joints  distended  with  masses 
of  fungous  granulations  without  much  suffering,  while  in  other  instances 
a  limited  disease  in  the  joint  will  cause  complete  disability  and  a  great  deal 


Fig.  195. — Knee-joints.    A,  normal  knee-joint;    B,  tubercular  hydrops;    O,  tubercular 
osteomyelitis  of  internal  condyle  of  femur.     (Albert.) 


of  suffering.  According  to  my  observation,  the  pain  is  usually  more  severe 
in  cases  where  the  granulations  are  scanty  than  when  the  synovial  mem- 
brane is  the  seat  of  extensive  fungosities.  As  a  point  in  differential  diag- 
nosis, it  may  be  said  that  in  osteal  tuberculosis  pain  is  present  from  the  be- 
ginning in  the  bone,  and  is  not  much  aggravated  by  the  joint  disease;  while 
an  almost  painless  primary  synovial  tuberculosis  is  followed  by  severe  pain 
with  nocturnal  exacerbations  as  soon  as  the  synovial  membrane  and  articu- 
lar cartilage  have,  been  destroyed  and  the  bone  has  been  secondarily  impli- 
cated in  the  inflammatory  process.  Absence  of  tenderness  away  from  the 
joint  and  its  presence  in  the  line  of  the  joint  would  indicate  rather  a  pri- 
mary synovial  tuberculosis  than  the  osteal  variety.     In  primary  synovial 


Fig.  196. — Dry  Tuberculosis  of  the  Shoulder-joint  (Caries  Sicca),  showing  Extensive 
Destruction  of  the  Head  of  the  Humerus. 


TUBEECULOSIS    OF    JOINTS.  577 

tuberculosis  in  the  hip-joint  the  pain  is  located  in  the  joint  and  the  groin; 
while  in  the  osteal  form,  during  the  early  stage  at  least,  it  is  usually  referred 
to  the  inner  aspect  of  the  knee. 

3.  Deformity. — Contraction,  lateral  deviations,  subluxations,  and  other 
abnormal  positions  usually  indicate  more  or  less  destruction  of  the  articular 
surfaces  of  the  bones  and  ligaments.  These  malpositions  are  not  seen  in 
articular  tubercular  hydrops  or  the  milder  forms  of  synovial  tuberculosis, 
while  we  find  different  degrees  of  one  or  more  of  them  nearly  in  every  case 
of  advanced  fungous  synovitis.  Watson  Cheyne  has  again  called  attention 
to  the  fact  that,  in  chronic  inflammation  of  joints,  the  explanation  of  Bonnet, 
that  contractions  are  caused  by  intraarticular  pressure,  is  no  longer  tenable, 
as  Luecke  (Deutsche  Zeitschrift  fur  Chirurgie,  B.  xxi,  H.  5)  has  shown  con- 
clusively that  in  fungous  disease  of  joints  the  flexed  position  is  induced  by 
the  irritation  due  to  the  inflammation,  as  in  that  posture  the  least  amount 
of  pain  is  incurred.  If  the  patient  now  attempt  to  walk  he  naturally  contracts 
all  the  muscles  so  as  to  avoid  any  movement  which  would  aggravate  the  pain. 
This  contracted  state  of  the  muscles,  however,  tends  still  to  heighten  the 
degree  of  flexion,  as  the  flexors  are  naturally  and  anatomically  stronger  and 
less  easily  fatigued  than  the  extensors.  Therefore,  the  longer  this  flexed 
position  has  been  maintained,  the  more  marked  it  becomes,  as  is  the  case  in 
paralysis  originating  in  the  nervous  centres.  Luecke  is  of  the  opinion  that 
in  chronic  joint-disease  the  posture  of  the  joint  is  adopted  voluntarily  or 
from  expediency  so  as  to  facilitate  the  use  of  the  limb  in  the  same  manner 
as  scoliolordosis  is  adapted  to  compensate  adduction,  disappearing  when  the 
patient  is  confined  to  bed,  as  its  only  purpose  is  the  avoidance  of  limping. 
The  posture  is  further  influenced  by  the  destruction  of  integral  parts  of  the 
joints;  adduction  in  the  hip- joint,  for  instance,  is  caused  by  destruction  of 
the  acetabulum,  as  the  varus  position  of  the  knee  is  due  to  destructive 
changes  affecting  the  internal  condyle  of  the  femur  or  the  inner  tuberosity 
of  the  tibia.  In  advanced  cases  of  synovial  tuberculosis  of  the  knee-joint 
the  joint  is  flexed,  the  leg  rotated  outward,  and  the  head  of  the  tibia  dis- 
placed backward.  In  the  hip-joint  the  disease  gives  rise  to  flexion  of  the 
thigh  upon  the  pelvis,  and  first  eversion,  but  later  inversion,  of  the  limb. 
After  separation  of  the  head  of  the  femur,  or  extensive  destruction  of  the 
articular  end  of  this  bone  and  the  acetabulum,  the  contour  of  the  region  of 
the  hip-joint  and  the  position  of  the  limb  simulate  dislocation  of  the  head 
of  the  femur  upon  the  dorsum  of  the  ilium.  Tubercular  disease  of  the  elbow- 
joint  gives  rise  to  flexion  and  pronation  of  the  forearm.  The  clinical  im- 
portance of  any  of  these  displacements  lies  in  the  fact  that  they  signify  a 
certain  amount  of  destruction  of  the  joint-structures,  thus  often  indicating 
surgical  interference  for  the  correction  of  the  deformity,  as  well  as  the  re- 
moval of  the  diseased  tissue.     Eemembering  the  frequency  of  tubercular 


678  PEINCIPLES    OP    SUKGEET. 

affections  of  joints,  as  a  rule,  there  is  little  difficulty  in  their  recognition,  if 
the  history,  course,  and  symptoms  are  carefully  studied  and  analyzed.  Konig 
justly  remarks  that  it  is  well  to  remember  that  articular  tuberculosis,  even 
if  the  disease  affect  a  large  joint,  is  practically  a  local  disease,  and  has  for 
a  long  time  little  or  no  influence  on  the  general  health  of  the  patient.  Thus, 
we  may  find  patients  presenting  all  the  appearances  of  robust  health  suffer- 
ing from  articular  tuberculosis.  The  tubercular  articular  hydrops  is  distin- 
guished from  a  catarrhal  or  rheumatic  synovitis  with  copious  effusion  by  its 
persistency  and  tendency  to  return  after  aspiration  or  after  active  use  of  the 
joint.  The  presence  of  flocculi  or  rice-bodies  in  a  joint  confirm  the  tuber- 
cular nature  of  the  affection.  A  tuberous  synovitis,  with  the  formation  of  a 
single  mass  of  fibrous  tissue,  sessile  or  pedunculated,  might  be  mistaken  for 
lipoma  arbor escens  or  gummata.  The  diagnosis  of  the  latter  will  be  cleared 
up  by  a  course  of  antisyphilitic  treatment,  which  should  always  be  instituted 
in  cases  of  doubt.  Tubercular  joint-abscess  is  distinguished  from  suppu- 
rative, gonorrhoeal,  or  rheumatic  synovitis  by  the  pain  being  less  and  the 
absence  of  all  signs  of  acute  inflammation.  The  local  conditions  in  fungous 
synovitis  are  so  characteristic  that  they  can  hardly  be  misinterpreted  by  a 
careful  observer.  The  presence  or  absence  of  fluid  in  the  joint  has  often  to 
be  determined  by  an  exploratory  puncture.  The  caries  sicca  of  Volkmann, 
or  dry,  pannous,  hyperplastic  synovitis  of  Hueter,  especially  as  found  in  the 
shoulder-joint,  might  be  mistaken  for  a  neurosis,  with  atrophy  of  the  mus- 
cles covering  the  joint.  The  differential  diagnosis  cannot  be  made  without 
the  examination  while  the  patient  is  fully  under  the  influence  of  an  anass- 
thetic.  If  the  affection  is  a  neurosis,  motion  will  be  found  unimpaired;  if  it 
is  tubercular,  the  mobility  of  the  joint  will  be  found  lessened  by  intraarticu- 
lar adhesions  and  cicatricial  contraction  of  the  capsule  of  the  joint. 

Prognosis. — Tuberculosis  of  a  joint  may  terminate  in  a  spontaneous 
cure  in  cases  in  which  the  intensity  of  the  infection  is  slight  or  the  re- 
sistance on  the  part  of  the  patient  is  so  great  that  the  fungous  granula- 
tions do  not  undergo  degenerative  changes,  but  are  converted  into  con- 
nective tissue.  A  partial  or  complete  synechia  of  the  cavity  of  a  joint  is 
often  one  of  the  unavoidable  results  in  such  cases,  leaving  the  joint  in  a 
permanently  stiff  condition.  This  endeavor  on  the  part  of  the  organism 
to  limit  the  extension  of  the  disease  is  often  observed  in  cases  in  which  the 
joint  affection  occurs  in  connection  with  osteal  tuberculosis.  As  soon  as  per- 
foration of  a  focus  into  a  joint  has  occurred  a  wall  of  granulation-tissue 
is  thrown  out  around  the  circumscribed  area  of  infection,  and,  under 
favorable  circumstances,  a  partition  of  cicatricial  tissue  is  formed  which 
isolates  the  infected  from  the  intact  portion  of  the  joint.  In  such  in- 
stances we  have  an  illustration  how  the  tubercular  process  is  retarded, 
and  sometimes  permanently  arrested,  by  the  transformation  of  granula- 


Fig.  197.— Pathological  Subluxation  of  the  Hip-joint  following  Extensive  Destruction 
of  the  Head  of  the  Femur  by  Tubercular  Cavities. 


TUBEECULOSIS    OF    JOINTS.  579 

tion-  into  connective  tissue.  For  such  a  favorable  termination  to  take 
place  it  is  necessary  that  the  tubercular  virus  should  be  attenuated  by  age 
or  want  of  a  proper  nutrient  medium,  or  that  the  pathogenic  effect  of  the 
bacilli  should  be  neutralized  by  an  adequate  resistance  on  the  part  of  the 
tissues  before  degenerative  changes  have  occurred  in  the  granulation- 
tissue.  The  course  of  articular  tuberculosis  is  so  variable  in  different  cases 
that  it  is  impossible,  during  the  early  stages  of  an  attack,  to  predict  any- 
thing certain  in  reference  to  the  probable  outcome.  A  spontaneous  cure 
is  more  likely  to  take  place  if  the  patient  is  young,  not  anaemic,  and,  at 
the  same  time,  well  nourished.  The  hygienic  surroundings  must  also  be 
taken  into  consideration  in  rendering  a  prognosis.  The  disease  shows 
greater  tendencies  to  limitation  in  children  than  in  persons  past  the  age 
of  puberty. 

Among  the  different  forms  of  joint  tuberculosis  the  tubercular 
hydrops  and  caries  sicca  are  the  most  benign,  and  in  these  cases  a  spon- 
taneous cure  is  most  frequently  realized  and  the  same  conditions  are  also 
most  amenable  to  successful  surgical  treatment.  The  caries  sicca  may, 
according  to  Konig,  terminate  in  a  spontaneous  cure  in  two  or  three  years, 
with  some  loss  of  motion  in  the  Joint.  It  is  sometimes  difficult  to  ascer- 
tain in  a  given  case  when  the  lesion  can  be  considered  as  cured.  As  the 
most  reliable  evidences  that  such  favorable  termination  has  taken  place 
must  be  considered  disappearance  of  swelling,  pain,  tenderness,  and 
restoration  of  function  as  far  as  this  can  be  expected.  The  patient  should 
not  be  permitted  to  use  the  limb  until  the  active  symptoms  of  inflamma- 
tion have  disappeared.  The  danger  to  life  arises  from  the  existence  of 
complications,  foremost  among  them  being  septic  infection,  pulmonary  or 
general  tuberculosis,  and  amyloid  degeneration  of  important  internal  or- 
gans. Septic  infection  is  caused  either  by  localization  of  pus-microbes 
brought  to  the  tubercular  focus  through  the  circulating  blood,  or,  what 
is  more  frequently  the  case,  through  an  infection-atrium,  created  by  a 
spontaneous  opening;  through  an  operation  wound;  an  exploratory 
puncture;  or,  finally,  through  a  fistulous  communication  with  the  joint. 
Many  neglected  cases  of  joint  tuberculosis  die  annually  of  pulmonary  or 
general  tuberculosis.  Billroth  states  that  in  sixteen  years  27  per  cent,  of 
bone  and  joint  tuberculosis  were  lost  in  this  way.  Konig,  from  a  table  of 
117  operations  for  tuberculosis,  found  that  after  four  years  16  per  cent, 
had  died  from  gelieral  tuberculosis.  If  a  patient  escape  death  from  septic 
infection  after  secondary  infection  with  pus-microbes,  he  is  liable  to  suc- 
cumb several  years  later  to  amyloid  degeneration  of  the  spleen,  the  liver, 
and  especially  the  kidneys,  with  its  accompanying  anasarca. 

Treatment. — As  spontaneous  cure  in  cases  of  joint  tiiberculosis  is 
more  frequently  the  exception  than  the  rule,  and  if,  finally,  it  does  take 


580  PRINCIPLES    OF    SUEGEEY. 

place  it  does  so  generally  after  the  limb  has  become  so  much  deformed 
that  it  is  useless  and  will  require  a  formidable  operation  to  restore  partial 
function,  it  is  evident  that  timely  surgical  treatment  should  be  adopted  to 
eradicate  the  disease,  preserve  function,  and,  at  the  same  time,  protect  the 
patient  as  far  as  can  be  done  against  general  infection. 

1.  Rest. — As  in  cases  of  osteotuberculosis,  rest  is  an  important  ele- 
ment in  the  treatment  of  tubercular  joints.  It  is  even  more  important  to 
secure  rest  for  an  inflamed  Joint  than  for  an  inflamed  bone,  as  the  inflam- 
mation is  always  greatly  aggravated  by  the  movements  in  the  joint  that 
necessarily  take  place  as  long  as  the  joint  is  used,  which  does  not  apply 
with  equal  force  to  cases  of  osteotuberculosis.  During  the  early  stage  of 
hip-joint  tuberculosis  rest  in  bed  and  extension  by  weight  and  pulley  are 
best  calculated  to  secure  rest  for  the  diseased  joint  and  to  guard  against 
deformity.  After  the  acute  symptoms  have  subsided  the  patient  should 
avail  himself  of  the  benefits  to  be  derived  from  out-door  air  and  exercise 
by  the  use  of  crutches  and  Hutchinson^s  shoe  or  Sayre's  extension-splint. 
The  best  method  to  procure  rest  by  treatment  in  ambuldndo  is  to  im- 
mobilize the  limb  in  a  plaster-of-Paris  splint,  which  does  not  necessarily 
confine  the  patient  to  his  room  or  bed.  If  one  of  the  lower  extremities  is 
to  be  incased  in  a  plaster  splint,  I  am  in  the  habit  of  applying  the  plaster- 
of-Paris  roller  over  tight-fitting,  knit  drawers,  which  protect  the  skin 
much  better  than  an  ordinary  roller  bandage.  All  bony  prominences 
should  be  protected  against  pressure  by  careful  padding  with  absorbent 
cotton.  If  the  hip- joint  is  the  seat  of  inflammation  the  splint  is  applied 
with  the  limb  in  the  extended  position,  while  the  patient  stands  on  the 
sound  limb  upon  a  low  stool,  as  in  this  position  autoextension  is  made  by 
the  weight  of  the  suspended  limb.  In  such  cases  the  splint  must  extend 
from  the  toes  and  embrace  the  entire  limb,  the  whole  pelvis,  and  abdo- 
men as  far  as  the  umbilicus,  and  the  opposite  limb  as  far  as  the  knee-joint. 
In  tuberculosis  of  the  knee-joint  the  splint  should  extend  from  the  toes 
to  the  groin,  and,  in  ankle-joint  affections,  from  the  toes  to  the  knee-joint. 
Immobilization  is  to  be  made  with  the  limb  in  such  a  position  that  in  case 
the  joint  should  become  permanently  stiff  the  limb  can  be  used  to  great- 
est advantage.  A  slight  degree  of  flexion  in  the  hip-  and  knee-  joints  is  to 
be  preferred  to  a  perfectly  straight  position.  In  inflammation  of  the 
shoulder-joint  the  limb  makes  the  necessary  counter-extension,  and  fix- 
ation of  the  joint  is  secured  by  confining  the  limb,  with  the  forearm  flexed, 
at  right  angles  to  the  side  of  the  chest,  by  strips  of  adhesive  plaster  or  a 
plaster-of-Paris  bandage.  The  hand  should  be  slightly  extended  in  im- 
mobilizing the  forearm  in  the  treatment  of  tuberculosis  of  the  wrist,  while 
the  forearm  is  flexed  at  a  right  angle  to  the  arm  in  tubercular  synovitis  of 
the  elbow-joint,  with  the  hand  in  position  half-way  between  pronation  and 


TUBEECULOSIS    OF    JOINTS.  581 

supination.  Early  immobilization  of  a  tubercular  joint  not  only  secures 
absolute  rest  for  the  joint,  but,  at  the  same  time,  this  treatment  prevents, 
to  a  great  extent,  subsequent  deformities.  Treatment  by  immobilization 
should  be  continued  until  all  symptoms  of  inflammation  have  subsided,  or 
until  more  radical  measures  become  necessary.  If  the  arthritis  has  al- 
ready resulted  in  contractures  the  treatment  by  extension  with  weight 
and  pulley  is  in  place,  and  should  be  continued  until  the  limb  has  been 
brought  in  proper  position  for  treatment  by  immobilization. 

2.  Aspiration. — In  tubercular  hydrops  the  intraarticular  effusion  is 
often  very  copious,  resulting  in  enormous  distension  of  the  capsule  of  the 
joint,  which,  if  continued  for  any  length  of  time,  must  necessarily  result 
in  great  weakening  of  the  joint.  Aspiration  nnder  these  circumstances 
relieves  the  distension  and  places  the  vessels  in  the  synovial  membrane  in 
a  better  condition  to  perform  their  function  in  the  subsequent  removal  of 
the  inflammatory  product  by  absorption.  After  evacuation  of  the  con- 
tents of  the  joint  the  limb  should  be  immobilized  and  rapid  reaccumula- 
tion  of  the  fluid  prevented  by  uniform,  equable  compression  of  the  joint 
by  strips  of  adhesive  plaster  or  rubber  bandage. 

3.  Tapping  and  lodoformization. — In  tubercular  hydrops  and  abscess 
of  a  joint  subcutaneous  evacuation  of  the  fluid  contents,  followed  by  iodo-. 
formization  practiced  in  the  same  manner  as  has  been  described  in  the 
treatment  of  tubercular  abscess,  yields  more  satisfactory  results  than 
simple  aspiration.  In  tubercular  hydrops  irrigation  of  the  joint  with  a 
3-per-cent.  solution  of  boric  acid  is  only  necessary  for  the  removal  of  rice- 
bodies;  if  such  are  not  present,  the  iodoform  mixture  may  be  injected  at 
once.  Krause,  during  a  period  of  eighteen  months,  treated  43  tubercular 
joints  by  means  of  iodoform  injections;  cases  were  treated  by  other  means, 
and  where  cure  without  operation  seemed  impossible,  but  in  which  fistulas 
were  not  yet  formed.  The  injections  were  repeated  at  intervals  of  two  or 
three  weeks.  Pain  was  greatly  relieved  by  this  treatment;  the  swelling 
yielded  much  more  slowly,  though  in  six  weeks  some  cases  showed  a  reduc- 
tion in  size  and  a  hardness  of  the  affected  parts.  The  abscess-cavities  fre- 
quently filled  again,  rapidly  at  first,  but  ultimately  reaccumulation  ceased. 
In  some  cases  fistu.la3  formed  at  the  seat  of  puncture,  which  first  discharged 
pus,  then  serum,  but  ultimately  healed  entirely.  In  a  fair  percentage 
treated  in  this  way  definitive  healing  was  obtained.  This  treatment 
promises  the  best  results  in  cases  where  granulation-tissue  is  scanty,  and 
where  the  inflammatory  product  has  not  undergone  extensive  caseation. 
This  treatment  of  tubercular  joints  has  had  a  very  extensive  trial  in  the 
clinic  of  Kush  Medical  College,  where,  during  the  last  ten  years,  hundreds 
of  patients  have  reaped  its  benefits.  In  well-splected  cases  I  know  of  no 
treatment  which  is  equal  to  it.    Iodoform  has  a  decided  antibacillary  effect 


583  PEINOIPLES    OF    SUEGEEY. 

in  uncomplicated  tuberculosis  of  joints;  it  is  useless  after  the  tubercular 
process  has  become  the  seat  of  infection  with  pyogenic  microbes.  Bill- 
roth opens  the  Joint;,  evacuates  its  contents  through  the  incision,  removes 
(if  present)  tubercular  sequestra,  rice-bodies,  and  tubercular  membranes, 
and  then  treats  the  joint  by  iodoformization.  In  general  practice,  how- 
ever, it  is  much  safer  to  follow  the  subcutaneous  method  by  puncturing 
the  joint  with  a  medium-sized  trocar,  using  the  cannula  for  evacuation, 
irrigation,  and  iodoformization.  Hahn  has  obtained  very  satisfactory  re- 
sults by  the  substitution  of  formalin  for  iodoform  in  the  treatment  of 
tubercular  arthritis,  tubercular  abscesses,  and  tubercular  empyema.  He 
uses  1  to  10  parts  of  a  35-per-cent.  solution  of  formalin  in  100  parts  of 
glycerin,  as  an  injection  after  the  abscess  has  been  evacuated  and  washed 
out  with  boric-acid  solution.  A.  M.  Phelps  incises  the  joint  freely,  fills  it 
with  pure  carbolic  acid,  which  is  allowed  to  remain  for  a  few  minutes,  when 
it  is  washed  out  with  pure  alcohol;  lastly,  the  joint  is  irrigated  with  a  weak 
solution  of  alcohol,  a  glass  drain  is  inserted,  and  the  usual  absorbent  aseptic 
dressing  is  applied. 

4.  Arthrectomy. — ^Excision  of  the  infected  tissues  in  primary  tuber- 
culosis of  the  synovial  membrane  has  been  practiced  for  a  number  of 
years,  and  the  results  of  this  treatment  have  been  quite  encouraging. 
Primary  synovial  tuberculosis,  without  any  foci  in  the  articular  ends  of 
the  bones  and  which  resists  the  treatment  by  tapping  and  intraarticular 
iodoformization,  should  be  treated  by  arthrectomy,  and  not  by  resection, 
as  by  the  former  operation  the  diseased  tissues  can  be  removed  eJEfectually 
without  unnecessary  loss  of  healthy  tissues  that  are  sacrificed  by  the  latter 
operation.  The  success  of  an  operation  for  tubercular  affections  depends 
largely  upon  the  thoroughness  with  which  the  operation  is  done  and  the 
absence  of  suppuration.  Arthrectomy  should  be  performed  before  fistu- 
lous openings  have  formed,  and  the  joint  must  be  opened  by  an  incision 
that  will  expose  every  nook  and  corner  of  the  capsule.  Of  the  many  in- 
cisions that  have  been  devised  for  opening  the  knee-joint,  the  one  I  shall 
describe  here  offers  the  greatest  advantages  and  is  open  to  the  least  ob- 
jections. The  old-fashioned  horseshoe  incision,  with  the  convexity 
directed  downward,  makes  it  very  difficult  to  suture  the  wound,  and  leaves 
a  scar  where  it  is  most  exposed  to  injury.  The  incision  carried  directly 
across  the  knee-joint,  if  the  patella  is  divided  at  the  same  time,  leaves, 
subsequently,  the  superficial  and  deep  parts  of  the  wound  directly  oppo- 
site; if  the  patella  is  preserved,  the  scar  of  the  external  incision  falls 
upon  the  most  prominent  part  of  the  patella,  which  is  again  a  great  dis- 
advantage. The  incision  which  for  several  years  I  have  always  selected 
in  opening  the  knee-joint  in  performing  arthrectomy  or  resection  is 
Hahn's  incision,  which  is  slightly  curved,  but  with  the  convexity  directed 


TUBEECULOSIS    OF    JOINTS.  '       583 

upward.  It  is  carried  from  the  most  dependent  portion  of  the  knee-joint, 
at  a  point  corresponding  to  the  most  prominent  part  of  the  internal 
condyle  of  the  femur,  in  a  gentle  curve  to  an  inch  above  the  upper  border 
of  the  patella,  and  from  here  downward  and  outward  to  a  point  opposite 
where  it  was  commenced.  The  short,  semilunar,  cutaneous  flap  is  now 
detached  and  turned  downward.  After  this  an  incision  is  carried  directly 
across  the  joint,  dividing  the  lateral  ligaments  and  crossing  the  patella 
transversely  at  its  centre.  The  patella,  at  this  step  of  the  operation,  is 
divided  with  a  saw.  The  upper  recesses  of  the  synovial  sac  are  freely 
opened  by  making  an  incision  on  each  side  of  the  upper  half  of  the 
patella,  which  is  carried  as  far  as  the  upper  recess  of  the  synovial  sac.  The 
rectangular  flap,  composed  of  the  upper  end  of  the  patella  with  its  muscu- 
lar attachments,  is  reflected,  which  exposes  every  portion  of  the  upper 
part  of  the  synovial  recess.     A  somewhat  similar  flap  is  made  of  the 


Fig.  198. — Hahn's  Incision  for  Arthrectomy,  or  Resection  of  the  Knee-joint. 

lower  half  of  the  patella  and  its  tendon,  reflected  in  a  downward  direction, 
by  which  the  tissues  underneath  that  portion  of  the  patella  and  its  liga- 
ment are  fully  exposed.  "With  the  knee-joint  thus  exposed  it  is  not  diffi- 
cult to  extirpate,  with  the  help  of  a  catch-forceps,  a  sharp  scalpel,  and  a 
pair  of  curved  scissors,  the  entire  capsule.  The  part  of  the  capsule  that 
will  be  found  most  difficult  to  remove  is  that  portion  which  covers  the 
popliteal  vessels  and  dips  down  behind  the  condyles  of  the  femur  and  be- 
hind the  tuberosities  of  the  tibia.  During  this  part  of  the  operation  the 
leg  must  be  forcibly  flexed  over  a  small  cushion,  or  the  fist  of  an  assistant, 
in  the  popliteal  space.  Arthrectomy  is  always  a  tedious  operation,  as  it  is 
absolutely  necessary  to  remove  all  of  the  infected  tissues  in  order  to  secure 
permanent  success.  If  the  patella  is  not  diseased  it  should  never  be  re- 
moved. After  the  capsule  has  been  extirpated  the  patella  is  united  by 
two  chromicized  catgut  sutures.  I  have  never  failed  in  obtaining  bony 
union  in  four  to  six  weeks  after  this  method  of  coaptation.     After  ex- 


584  PEINCIPLES    OF    SURGERY. 

tirpation  of  the  capsule,  and  before  the  elastic  constrictor  is  removed,  the 
whole  surface  should  be  once  more  irrigated  with  a  hot,  aqueous  solution 
of  iodine  or  salt  solution,  after  which  it  is  rubbed  off  with  dry  iodoform 
gauze,  in  order  to  remove  any  detached  fragments  that  have  not  been 
washed  away.  The  whole  surface  is  now  freely  sprinkled  with  impalpable 
iodoform,  which  is  rubbed  into  the  surface.  Before  the  constrictor  is 
removed  the  wound  is  packed  with  aseptic  gauze,  the  flaps  are  laid  over  it, 
and  manual  compression  made  for  five  to  ten  minutes  after  the  removal 
of  the  constrictor,  with  the  limb  in  an  elevated  position.  This  simple 
procedure  serves  an  admirable  purpose  in  controlling  capillary  haemor- 
rhage, and  reduces  the  necessity  of  recourse  to  ligature  to  a  minimum. 

After  all  the  bleeding  has  been  arrested  the  patella  is  sutured,  and 
the  deep  parts  of  the  wound  are  united  by  buried  sutures.  Tubular  drain- 
age can  usually  be  dispensed  with,  as  a  capillary  drain  composed  of  a  few 
threads  of  catgut  will  answer  an  excellent  purpose,  and  will  not,  like  the 
tubular  drain,  necessitate  an  early  change  of  dressing.  The  external  in- 
cision is  closed  with  silk-worm-gut  sutures,  the  line  of  suturing  being  out 
of  the  way  of  the  patella,  the  parts  united  with  the  buried  sutures  being 
covered  throughout  by  the  external  flap.  A  careful  h^mostasis  and  rigid 
antiseptic  precautions  will  make  it  unnecessary  to  change  the  dressing 
earlier  than  the  end  of  the  second  week,  and  on  this  account  I  prefer  to 
immobilize  the  limb  in  a  bracketed  plaster-of-Paris  splint,  or  a  plastic 
posterior  splint,  applied  over  a  copious  antiseptic  dressing.  The  limb  must 
be  kept  in  an  elevated  position  for  at  least  six  hours  after  the  operation, 
so  as  to  diminish  the  amount  of  parenchymatous  haemorrhage.  If  all  the 
infected  tissues  have  been  removed  and  the  wound  remain  in  an  aseptic 
condition,  the  external  wound  will  be  found  closed  in  the  course  of  two 
or  three  weeks.  A  fair  restoration  of  function  with  partial  mobility  of  the 
joint  can  be  expected  in  favorable  cases.  Passive  motion  must  be  delayed 
until  the  patella  has  firmly  united,  which  will  require  from  three  to  four 
weeks  in  children  and  nearly  twice  this  length  of  time  in  adults.  After 
the  patella  has  united  and  the  external  Avound  is  completely  healed,  re- 
covery is  hastened  by  passive  motion,  massage,  and  use  of  the  faradic  cur- 
rent. Arthrectomy  has  a  promising  future  in  the  treatment  of  primary 
synovial  tuberculosis  of  the  knee-joint,  but  for  well-known  anatomical 
reasons  it  is  not  equally  applicable  in  the  treatment  of  synovial  tubercu- 
losis of  any  other  of  the  larger  joints.  It  is  possible  that  the  operation 
will  be  modified  and  sufficiently  perfected  in  the  future  so  as  to  be  more 
applicable  in  the  treatment  of  synovial  tuberculosis  of  the  hip-  and 
shoulder-  joints.  In  a  number  of  cases  of  tuberculosis  of  the  elbow-joint 
I  obtained  an  excellent  result  from  arthrectomy  combined  with  temporary 
resection  of  the  olecranon  process.     This  process  was  divided  obliquely 


TUBERCULOSIS    OF    JOINTS.  585 

with  a  saw  at  its  junction  with  the  shaft  of  the  ulna,  and,  after  the  extir- 
pation of  all  of  the  infected  soft  tissues  of  the  joint,  the  process  was 
fastened  in  its  proper  place  with  an  aseptic  ivory  nail  or  chromicized  cat- 
gut sutures.    The  functional  result  was  satisfactory. 

5.  Atypical  Resection. — The  incision  (superficial  and  deep)  in  atypical 
and  typical  resection  of  the  knee-joint  should  be  the  same  as  has  been  de- 
scribed above.  The  patella  is  divided  transversely,  and  if  it  does  not  contain 
a  tubercular  focus  it  is  not  necessary  or  advisable  to  remove  it,  as  its  con- 
tinuity after  resection  can  be  restored  by  suturing  with  a  du.rable  form  of  cat- 
gut. An  atypical  resection  consists  in  the  removal  of  tubercular  foci  in  the 
epiphyseal  extremities  of  the  bones  that  enter  into  the  formation  of  the  joint, 
without  removing  the  entire  articular  extremities  by  a  transverse  section 
with  the  saw.  The  unnecessary  removal  of  the  epiphyseal  extremities 
should  especially  be  avoided  in  the  case  of  children,  as  the  removal  of  one 
or  both  centres  of  growth  of  bone  will  result  in  so  much  shortening  of  the 


Fig.  199. — Interrupted  Plaster-of-Paris  Splint  for  Resection  of  the  Knee-joint. 

limb  subsequently  as  often  to  render  it  not  only  perfectly  useless,  but 
it  becomes  a  burdensome  appendage.  In  children  atypical  resection  should 
be  practiced  in  all  cases  where  all  the  foci  in  the  articular  extremities  can 
be  reached  and  removed  by  this  method.  The  proper  instruments  to  be 
used  in  this  operation  are  the  chisel,  bone-forceps,  and  sharp  spoon.  After 
the  joint  has  been  freely  opened,  the  articular  surfaces  are  carefully  in- 
spected for  evidences  of  deep-seated  foci.  If  perforation  into  the  joint  has 
taken  place  the  cavity  is  freely  exposed  from  the  articular  surface,  and 
all  of  the  infected  tissues  are  removed  with  chisel  and  sharp  spoon.  It 
is  important  not  only  to  remove  necrosed  bone,  granulation-tissue,  and 
caseous  material,  but  also  the  surrounding  osteoporotic  zone  of  bone  that 
possibly  might  contain  tubercle  bacilli.  A  deep-seated  focus  may  be  sus- 
pected and  should  be  searched  for  if  the  articular  cartilage  has  become 
detached  over  a  greater  or  less  extent.  Explorations  with  a  small  per- 
forator can  be  made  in  different  directions  from  the  articular  surface  in 


586  PEINCIPLES    OF    SUEGEKY. 

searching  for  deep-seated  foci.  If  the  articular  cartilage  has  become  de- 
tached over  a  considerable  area  by  granulations  underneath  it,  it  should 
be  removed,  and  the  exposed  bone  must  be  subjected  to  another  careful 
examination  for  the  purpose  of  locating  and  treating  deep-seated  foci.  A 
circumscribed  area  of  great  vascularity  is  a  suspicious  indication  and  calls 
for  a  limited  excavation  with  a  small,  sharp  spoon  for  diagnostic  purposes. 
It  is  well  for  the  surgeon  to  remember  that  primary  osteotuberculosis 
with  secondary  involvement  of  a  joint  usually  consists  of  more  than  one 
focus  in  one  or  both  epiphyseal  extremities.  A  tubercular  infarct  is  gen- 
erally recognized  by  examining  the  articular  surface,  as  the  cartilage  or 
the  exposed  portion  of  the  wedge-shaped  sequestrum  presents  appearances 
of  necrosis  that  cannot  be  mistaken.  After  the  extraction  of  the  seques- 
trum the  tubercular  cavity  is  submitted  to  the  same  treatment  as  when 
dealing  with  a  granulating  or  caseous  focus.  In  primary  synovial  tubercu- 
losis, with  extension  of  the  disease  to  the  subjacent  bone,  it  becomes 
necessary  to  remove  the  honey-combed,  softened  bone  over  the  entire 
surface  with  the  sharp  spoon  and  chisel.  Before  the  operation  is  ex- 
tended to  the  bone  in  osteotuberculosis  it  is  always  necessary  first  to 
extirpate  with  knife  and  scissors  the  infected  soft  structures  of  the  joint, 
the  synovial  membrane,  and  ligaments,  as  otherwise  the  healthy  vascular 
bone  may  become  an  infection-atrium  for  traumatic  infection, — a  not  very 
infrequent  and  serious  complication  after  operations  on  bones  and  joints 
for  tubercular  affections. 

Wartmann,  after  giving  a  careful  account  of  the  results  following  ex- 
cision of  tubercular  joints  in  the  hospital  practice  of  Feurer,  gives  the 
statistics  of  837  cases  of  excision  of  joints  for  tuberculosis  from  the 
practice  of  different  operators.  Of  this  number  225  died.  Of  the  fatal 
cases,  in  26  death  followed  the  operations  closely,  and  resulted  from  acute 
tuberculosis,  probably  induced  by  the  operation.  Konig  observed  16  cases 
in  his  own  practice  in  which  miliary  tuberculosis  followed  almost  imme- 
diately after  operations  on  bones  and  joints  for  tubercular  affections.  Konig 
states  that  the  secondary  or  reinfection  sets  in  seven  to  ten  days  after  opera- 
tion, which  may  have  been  perfectly  aseptic,  with  healing  of  the  wound  by 
primary  union.  The  secondary  tubercular  infection  appears  either  as  an 
acute  general  miliary  or  pulmonary  tuberculosis,  or  tubercular  meningitis, 
terminating  in  death  three  or  four  weeks  after  the  operation.  It  is  not  diffi- 
cult to  conceive  the  modus  opercundi  of  such  an  occurrence.  The  resection 
wound  opens  numerous  veins  in  the  bone,  the  lumina  of  which  remain 
patent,  ready  for  the  introduction  of  minute  fragments  of  granulation-tissue 
or  bacilli,  which,  on  entering  the  venous  circulation,  are  the  direct  cause 
of  metastatic  tuberculosis  in  distant  organs.  We  must  take  it  for  granted 
in  such  cases  that  a  tubercular  focus,  during  the  operation,  furnished  the 


TUBERCULOSIS    OF    JOINTS.  587 

essential  infected  fragments  of  granulation-tissue,  or  free  bacilli  are  aspi- 
rated or  forced  into  the  openings  of  wounded  vessels,  and  through  them 
gain  entrance  into  the  general  circulation.  To  guard  against  such  an  acci- 
dent it  is  necessary  to  remove  from  the  joint  all  possible  sources  of  infection 
before  operating  on  the  articular  extremities.  Cartilage  that  remains  firmly 
attached  to  the  bone  may  be  left.  After  all  foci  have  been  radically  elimi- 
nated, the  field  of  operation  is  flushed  with  an  antiseptic  solution,  and,  after 
drying  and  iodoformization,  the  bone-cavities  are  packed  with  antiseptic  de- 
calcified bone-chips,  and  the  operation  is  completed  in  the  same  manner  as 
in  arthrectomy. 

The  treatment  of  bone-cavities  with  decalcified  bone-packing  is  of  the 
greatest  utility  in  atypical  resection.  An  atypical  resection  with  subsequent 
implantation  of  decalcified  bone  has  for  its  objects  complete  removal  of  the 
infected  tissues  in  the  joint  and  the  surrounding  bone,  and  the  partial  res- 
toration of  the  parts  destroyed  by  disease  or  removed  during  the  operation. 
In  atypical  resection  of  the  knee-joint  it  is  not  uncommon  that  nearly  an 
entire  condyle  of  the  femur  or  tuberosity  of  the  tibia  must  be  removed.  In 
such  cases  the  surgeon  aims  at  bony  union  between  the  articular  ends  of 
the  bones,  which  is  accomplished  in  the  most  satisfactory  manner  by  plac- 
ing the  parts  in  a  condition  to  repair  the  lost  bone-tissue,  which  may  be 
done  by  filling  the  defect  with  decalcified  bone-chips.  I  have  repeatedly 
made  excavations  in  one  of  the  condyles  of  the  femur  and  in  the  head 
of  the  tibia  from  the  joint  surface,  the  size  of  a  small  orange,  and  ob- 
tained bony  ankylosis,  with  the  limb  in  a  good  position,  by  filling  the 
cavities  with  bone-chips.  As  the  bone-chips  are  always  iodoformized  be- 
fore implantation,  they  serve  a  useful  purpose  not  only  by  furnishing 
a  temporary  scaffolding  for  the  reparative  material,  but  they  constitute 
a  valuable  therapeutic  measure  in  the  prevention  of  a  local  recurrence 
of  the  disease  in  case  tubercle  bacilli  should  remain  in  the  cavity  or 
its  immediate  vicinity.  Immobilization  of  the  limb  after  resection 
should  be  continued  until  the  process  of  repair  has  been  completed, 
which,  under  the  most  favorable  conditions,  requires  from  six  weeks  to 
two  months.  Atypical  resections  can  be  made  use  of  in  the  treatment  of 
all  joints  by  resorting  to  temporary  resection  of  bony  prominences  which 
are  in  the  way  of  free  access  to  the  cavity  of  the  joint.  In  atypical  resection 
of  the  hip-joint,  for  instance,  the  greater  trochanter  is  temporarily  detached, 
which  at  once  exposes  the  neck  of  the  femur  freely,  and  after  dislocation  of 
the  head  of  the  femur  the  diseased  parts  of  the  joint  are  exposed  for  efficient 
direct  treatment.  The  removal  of  the  greater  trochanter  is  seldom  neces- 
sary, as  it  is  only  exceptionally  involved  by  the  tubercular  process.  After 
the  operation  is  completed  the  trochanter  is  sutured  in  position  with  strong 
catgut,  and  this  method  of  direct  fixation  never  fails  in  securing  bony  union 


588  PEINCIPLES    OF    SUEGERY. 

if  the  wound  remains  aseptic.  The  elbow-joint  is  most  accessible  through  a 
long,  straight,  posterior  incision,  and  after  temporary  resection  of  the  olec- 
ranon process.  Atypical  resection  of  the  ankle-joint  can  be  done  through 
two  lateral  incisions,  after  temporary  resection  of  the  malleoli,  with  chisel 
and  sharp  spoon.  In  all  resections,  atypical  and  typical,  ignipuncture  is  in- 
dicated after  the  excision  has  been  completed,  if  any  portion  of  the  bone  is 
abnormally  osteoporotic,  as  this  procedure  will  stimulate  the  process  of  re- 
pair, and  may  prove  useful  in  destroying  infected  tissues,  which,  from  their 
macroscopical  appearance,  indicate  a  healthy  condition. 

6.  Typical  Resection. — In  typical  resection  one  or  both  articular  ex- 
tremities are  sawn  across  and  removed.  In  the  hip-joint  it  implies  the  ex- 
cision of  the  head,  neck,  and  part  or  the  whole  of  the  greater  trochanter  of 
the  femur.  A  typical  resection  of  the  wrist- joint  means  the  removal  of  the 
•entire  carpus,  with  or  without  the  articular  surfaces  of  the  radius,  ulna,  and 
metacarpal  bones.  In  a  typical  resection  of  the  shoulder- joint  the  head  of 
the  humerus  is  removed.  In  the  knee-joint  the  operation  means  excision  of 
the  articular  surfaces  of  the  femur  and  tibia;  in  the  elbow-joint,  of  the 
humerus,  radius,  and  ulna;  in  the  ankle,  of  the  tibia,  fibula,  and  astragalus. 
Typical  resections  are  generally  made  for  tubercular  affections  of  the 
shoulder,  hip,  and  wrist-joint.  In  the  remaining  large  joints  it  is  more  fre- 
quently resorted  to  in  adults  than  children.  In  children  the  operation  is  lim- 
ited, with  the  exception  of  the  shoulder-,  hip-,  and  wrist-  joints,  to  cases 
where  the  articular  extremities  are  so  extensively  diseased  that  an  atypical 
resection  would  fail  in  removing  all  of  the  infected  tissues.  Eemoval  of  the 
diseased  synovial  membrane  and  ligaments  should  precede  section  of  the 
bones  with  the  saw  wherever,  from  the  anatomical  construction  of  the  joint, 
this  can  be  done.  In  the  hip-  and  shoulder-  joints  the  head  of  the  bone 
must  be  removed  first  before  the  soft  structures  of  the  joint  can  be  extir- 
pated. The  operation  best  adapted  for  resection  of  the  hip-joint  is  the  one 
by  which  the  trochanter  major  is  preserved.  In  this  operation  the  section 
of  the  bone  must  be  made  with  a  chisel.  The  entire  head  of  the  femur  and 
as  much  of  the  neck  as  is  indicated  by  the  extent  of  the  disease  are  removed 
by  the  use  of  the  chisel.  The  capsular  ligament  is  removed  as  thoroughly  as 
possible,  and  the  acetabulum  is  scraped  out  with  a  sharp  spoon.  Pro- 
vision for  drainage  must  be  made  in  all  hip- joint  resections.  The  after- 
treatment  consists  of  rest  in  bed  upon  a  smooth  mattress,  with  the  limb  ex- 
tended by  weight  and  pulley  in  an  abducted  position.  This  is  the  usual 
method  of  fixation  of  the  resected  hip-joint.  The  author  has  substituted 
for  it  fixation  by  means  of  a  fenestrated  plaster-of-Paris  splint,  which,  from 
his  experience,  he  regards  as  a  decided  improvement,  as  by  it  the  limb  is  at 
once  placed  in  a  desirable  position,  in  which  it  is  maintained  until  the  heal- 
ing process  is  completed.    After  six  weeks  the  patient  is  allowed  to  walk  on 


TUBEECULOSIS    OF    JOINTS.  589 

crutches,  with  a  raised  sole  under  the  shoe,  worn  on  the  opposite  side  (Hutch- 
inson's shoe),  so  that  the  limb  on  the  resected  side  makes  the  necessary 
autoextension.  During  the  night  extension  is  applied  for  eight  months  or 
a  year,  in  order  to  prevent  unnecessary  shortening.  Eversion  and  inversion 
of  the  limb  while  the  patient  is  in  bed  are  prevented  either  by  a  Yolkmann 
railway-splint  or  by  supporting  the  limb  with  sand-bags,  applied  to  each 
side.  Immobilization,  after  resection  of  the  shoulder-,  elbow-,  wrist-,  knee-, 
and  ankle-  joints,  is  best  secured  in  a  plaster-of-Paris  dressing,  which  also 
serves  an  excellent  purpose  in  keeping  the  antiseptic  dressing  in  situ. 

Temporary  resection  of  the  olecranon  process  in  excision  of  the  elbow- 
joint  has  yielded  excellent  results  in  my  hands,  as  by  it  the  insertion  of  the 
triceps  muscle  is  not  disturbed.  The  resected  olecranon,  after  the  removal 
of  any  foci  it  may  contain,  is  riveted  to  the  denuded  surface  of  the  shaft  of 
the  ulna  with  a  sterilized  ivory  or  bone  nail  or  chromicized  catgut  sutures, 
after  the  resection  has  been  completed.  The  forearm  is  immobilized  in  a 
semiflexed  position  until  bony  union  between  the  shaft  of  the  ulna  and 
olecranon  process  has  taken  place,  which  usually  requires  about  six  weeks. 
After  this  time  passive  motion  and  massage  should  be  made  to  increase  the 
mobility  of  the  joint.  A  straight,  single  incision  upon  the  dorsal  side  is  best 
adapted  for  resection  of  the  wrist-joint,  as  the  extensor  tendons  of  the  hand 
and  fingers  can  be  drawn  aside  sufficiently  to  afford  ample  room  for  the  re- 
moval of  the  entire  carpus.  In  the  after-treatment  of  excision  of  the  wrist 
the  forearm  and  hand  as  far  as  the  metacarpo-phalangeal  joints  are  incased 
in  a  plaster-of-Paris  splint,  with  the  hand  in  a  slightly-extended  position. 
Immediate  fixation  of  the  resected  ends  by  means  of  bone  or  ivory  nails,  after 
excision  of  the  knee,  is  superfluous,  as  the  parts  can  be  kept  in  accurate 
position  by  ordinary  fixation  dressings.  In  knee-joint  resections  the  section 
through  the  bones  must  be  made  in  such  a  manner  that  when  the  sawn  sur- 
faces are  brought  in  apposition  the  leg  will  be  slightly  flexed,  as  this  position 
enables  the  patient  to  walk  more  gracefully  than  with  a  straight,  stiff  limb. 
The  artificial  support  must  not  be  removed  until  firm  bony  union  has  taken 
place,  which  will  require  from  two  to  three  months,  according  to  the  pa- 
tient's general  health  and  age. 

7.  Amputation.  —  Amputation  must  be  reserved  for  cases  presenting 
special  indications.  It  is  the  only  operation  that  promises  any  benefit  if  the 
patient  suffer  at  the  same  time  from  tuberculosis  of  other  organs,  provided 
the  general  conditions  furnish  no  positive  contraindications.  It  is  also  in- 
dicated if  a  tubercular  abscess  has  perforated  the  capsule  of  a  joint  and  has 
extensively  infiltrated  the  surrounding  tissues.  This  condition  is  to  be  ex- 
pected if  the  limb  has  become  oedematous  some  distance  from  the  joint. 
The  fiaps  must  be  taken  from  the  side  of  the  limb  where  the  skin  is  in  the 
best  condition,  and  the  incision  through  the  deeper  tissues  must  be  made 


590  PEINCIPLES    OF    SURGEKT. 

through  healthy  tissue.  It  is  astonishing  how  rapidly  such  wounds  heal^  and 
how  quickly  patients  will  recover  after  amputations  for  extensive  local  tuber- 
cular processes,  even  in  patients  greatly  emaciated  by  the  disease. 


CHAPTER  XXIII. 

TUBEECULOSIS    OF    TeNDON-SHEATHS,    ETC. 
TUBEECULAE   TENDO-VAGINITIS. 

TuBEECULOSis  of  the  tendon-sheathS;,  or,  as  Hueter  termed  this  affec- 
tion, tendo-vaginitis  granulosa,  has  been  only  quite  recently  recognized  and 
described  as  a  primary  local  tuberculosis. 

Pathology. — -Hueter  was  of  the  opinion  that  this  affection  is  seldom  met 
with  as  a  primary  lesion,  but  that  it  appears  usually  as  a  complication  of 
joint  tuberculosis.  As  a  secondary  lesion  it  is  a  frequent  concomitant  of 
osteal  and  synovial  tuberculosis  by  direct  extension  of  the  inflammation  from 
the  primary  focus  to  tendon-sheaths.  Volkmann  gave  an  able  and  accurate 
description  of  tendon-sheath  tuberculosis  in  1875,  but  at  that  time  he  was 
not  aware  of  its  tubercular  nature.  The  first  scientific  treatise  on  this  afEec- 
tion  came  from  the  clinic  at  Gottingen  by  Eiedel,  who  showed  that  the  rice- 
bodies  so  commonly  found  in  the  so-called  fibrinous  hydrops  of  the  tendon- 
sheaths,  or  hygroma  of  the  flexor  tendons  of  the  hand,  always  indicated  a 
synovial  tuberculosis.  Another  important  paper  on  the  same  subject  was 
published  by  Beger,  who  reports  4  cases  that  occurred  in  the  clinic  at  Leipzig. 
The  chronic  tendo-vaginitis,  or  compound  ganglia  of  the  old  authors,  has 
been  shown  to  be,  on  careful  clinical  observation,  microscopical  examination, 
and  bacteriological  research,  cases  of  local  tuberculosis.  The  extension  of 
tubercular  processes  along  tendon-sheaths  from  a  tubercular  joint  after  per- 
foration of  the  capsule  has,  for  a  long  time,  been  known  to  occur,  but  as  a 
primary  lesion  it  has  only  recently  been  added  to  the  long  list  of  surgical 
lesions  of  a  tubercular  character.  As  compared  with  other  tubercular  affec- 
tions, primary  tendon-sheath  tuberculosis  is  quite  rare,  as  it  constitutes  only 
1  or  ^  per  cent,  of  the  cases  in  the  statistics  of  local  tubercular  lesions. 
When  this  affection  occurs  primarily  and  independently  of  tuberculosis  of 
an  adjacent  bone  or  joint,  infection  with  the  bacillus  of  tuberculosis  takes 
place  by  localization  of  floating  microbes  in  some  small  vessel,  and  subse- 
quently the  pathological  processes  in  the  tendon-sheaths  resemble  those  of 
tubercular  joints.  In  some  cases  the  products  of  the  disease  are  massive 
granulations  that  occupy  the  inner  surface  of  the  tendon-sheaths;  in  others 
the  granulations  are  less  abundant,  but  a  copious  synovial  exudation  is 
thrown  out;  while  in  a  third  class  the  granulations  form  hard,  white  masses, 
the  so-called  corpora  oryzoidea,  which  either  remain  attached  to  the  inner 
surface  of  the  sheath,  or,  after  their  separation,  are  found  as  loose  bodies. 
In  the  form  of  tendo-vaginitis  which  corresponds  with  the  fungous  variety 

(591) 


592  PEINCIPLES    OF    SUEGEKY. 

of  tubercular  synovitis,  the  granulations  form  a  layer  of  from  1  to  4  lines 
in  thickness  upon  the  inner  surface  of  the  sheath.  The  tendon  itself  is  cov- 
ered with  a  somewhat  thinner  layer  of  granulation-tissue,  the  granulations 
penetrating  the  substance  of  the  tendon  between  the  bundles  of  connective- 
tissue  fibres,  where,  by  absorption  and  pressure  atrophy,  they  cause  extensive 
destruction  of  tissue.  In  this  manner  the  tendon  becomes  so  much  weakened 
that  it  ruptures  on  the  slightest  traction,  or,  if  the  disease  has  progressed  still 
further,  the  loss  of  continuity  becomes  complete  without  a  trauma.  The 
inrinsic  tendency  of  the  disease  consists  in  progressive  extension  by  continu- 
ity of  structure  along  the  course  of  the  tendon  primarily  affected,  and  when 
this  tendon  is  part  of  a  compound  tendon  the  disease  gradually  creeps  from 
tendon  to  tendon  until  all  the  sheaths  are  involved.  As  this  affection  is  met 
with  most  frequently  in  the  tendon-sheaths  surrounding  the  carpus,  and  as 
these  sheaths  are  not  infrequently  in  direct  communication  with  the  wrist- 
joint  by  means  of  small  synovial  sacs,  it  extends  to  the  joint  by  continuity 
of  surface.  When  no  such  direct  connection  exists  between  the  tendon- 
sheath  and  the  subjacent  joint,  the  joint  may  become  secondarily  involved 
after  the  granulations  have  perforated  the  capsule.  ISText  to  the  region  of 
the  wrist-joint  the  tendo  Achillis,  the  patellar,  and  other  tendons  about  the 
knee-joint  are  most  frequently  affected.  In  tuberculosis  of  the  sheaths  of 
the  tendons  of  the  deep  flexors  of  the  fingers  the  swelling  is  often  large,  ex- 
tending from  the  lower  portion  of  the  palm  of  the  hand  underneath  the 
annular  ligament  to  the  middle  of  the  forearm.  Underneath  the  annular 
ligament  the  swelling  is  constricted  by  this  structure,  which  gives  rise  to  con- 
siderable bulging  in  the  palm  of  the  hand  and  over  the  lower  ant-erior  aspect 
of  the  forearm  (compound  ganglion  of  Syme).  The  fluctuating  wave  can  be 
distinctly  felt  above  and  below  the  annular  ligament,  showing  that  the  two 
swellings  are  in  direct  communication.  The  tubercular  product  imdergoes 
the  same  pathological  regressive  changes  as  in  synovial  tuberculosis.  If  a 
sufficient  number  of  tubercle  bacilli  is  present  in  the  granulation-tissue  the 
cells  are  destroyed  by  coagulation-necrosis  and  caseation,  the  fungous  masses 
breaking  down  into  an  amorphous,  granular  detritus.  At  this  stage  perfora- 
tion of  the  tendon-sheath  may  take  place  in  an  outward  direction,  and  a  sub- 
cutaneous tubercular  abscess  develops.  If  such  abscess  open  spontaneously, 
or  is  incised  without  regard  to  aseptic  precautions,  infection  with  pus-mi- 
crobes will  lead  to  acute  suppurative  inflammation,  which  will  often  result 
disastrously  from  rapid  extension  of  the  phlegmonous  inflammation  and  sep- 
tic infection.  The  occurrence  of  rice-bodies  in  tendon-sheath  and  synovial 
tuberculosis  can  be  traced  to  a  specific  action  of  the  bacillus  of  tuberculosis 
on  the  tissues.  Konig  attributes  to  this  bacillus  properties  which  place  it 
among  the  agents  that  produce  fibrinous  inflammation.  The  rice-bodies  in 
the  tendon-sheaths,  the  seat  of  a  chronic  inflammation,  he  considers  as  the 


TUBEKCULAE   TENDO-VAGINITIS.  593 

product  of  a  fibrinous  inflammation  caused  by  the  action  of  the  bacillus  of 
tuberculosis.  Mcaise,  Poulet,  and  Villard  examined  4  cases  of  hygroma  con- 
taining rice-bodieSj  and  found  in  all  of  them  the  bacillus  of  tuberculosis. 

Symptoms  and  Diagnosis. — Tuberculosis  of  the  tendon-sheaths  is  an  ex- 
ceedingly chronic  afilection.  The  disease  is  not  painful,  and  patients  often 
continue  to  follow  their  occupation  after  a  number  of  tendons  have  become 
involved  and  the  swelling  has  reached  considerable  dimensions.  The  swell- 
ing increases  in  length  in  the  direction  of  the  tendon  first  affected,  and  if 
the  disease  extend  to  neighboring  sheaths  it  branches  out  in  the  direction 
of  the  tendons  afilected.  In  9  out  of  10  cases  it  attacks  a  flexor  or  extensor 
tendon  in  the  region  of  the  wrist-joint,  and  then  extends  upward  and  down- 
ward in  the  direction  of  the  tendons.  In  tubercular  hydrops  of  the  tendon- 
sheaths  the  swelling  often  attains  great  size.  In  one  such  case  I  found  the 
palm  of  the  hand  the  seat  of  a  swelling,  the  size  of  a  large  orange,  that  com- 
municated with  a  smaller  swelling  above  the  annular  ligament  of  the  wrist- 
joint.  In  the  fungous  variety  the  swelling  imparts  to  the  palpating  finger 
a  semielastic  resistance,  and  fluctuation  is  either  entirely  absent  or  not  well 
marked.  If  rice-bodies  are  present  in  considerable  number,  alternate  pressure 
over  the  lower  and  upper  parts  of  the  swelling  produces  a  distinct  sensation  of 
crepitation.  The  disease  often  extends  to  the  middle  of  the  forearm,  and  in 
this  locality  attacks  the  muscular  tissue  in  the  same  manner  as  the  tendons 
farther  below.  Extension  to  a  joint  is  attended  by  symptoms  that  point  to 
synovial  tuberculosis.  The  symptoms  are  so  characteristic  that  a  correct 
diagnosis  can  often  be  made  on  first  sight.  The  only  affections  that  must 
be  excluded  are  the  ordinary  ganglion  of  tendon-sheaths  and  acute  plastic 
tendo-vaginitis.  A  ganglion  always  remains  as  a  circumscribed  swelling 
without  manifesting  any  tendencies  to  extend.  The  contents  of  a  ganglion 
are  a  gelatinous  mass,  of  the  color  and  consistence  of  clarified  honey.  After 
evacuation  of  the  sac  no  swelling  remains,  as  the  cyst-wall  is  not  much  thick- 
ened. A  plastic  tendo-vaginitis,  resulting  from  injury  or  overexertion,  is 
an  acute  afileetion  not  attended  by  much  efliusion  or  inflammatory  exudation. 
The  tendon-sheath  is  abnormally  dry,  giving  rise  to  friction-sounds  which 
can  be  plainly  felt  and  often  heard  as  the  tendon  moves  within  the  inflamed 
and  roughened  sheath. 

Prognosis. — Spontaneous  cure  is  the  exception,  progressive  extension 
the  rule.  The  danger  from  regional  extension  arises  from  the  tendencies  of 
the  disease  to  invade  adjacent  joints,  and  to  extend  from  tendon  to  tendon, 
and  finally  along  these  to  the  respective  muscles.  There  is  no  reason  why, 
occasionally  at  least,  tendon-sheath  tuberculosis  should  not  be  folloAved  by 
pulmonary  or  general  tuberculosis  in  consequence  of  secondary  infection. 

Treatment. — The  use  of  external  applications,  compression  and  aspira- 
tion, are  of  doubtful  utility  in  the  treatment  of  this  affection.    Tapping,  fol- 


594  PEINCIPLES    OF    SUKGEEY. 

lowed  by  iodoformization,  promises  more^  especially  in  cases  of  tubercular 
hydrops  with  few  or  no  rice-bodies.  As  the  rice-bodies  contain  the  essential 
cause  of  the  disease,  it  will  usually  be  found  necessary  to  remove  them  in 
order  to  effect  a  permanent  cure.  Kemoval  of  these  bodies,  as  well  as  ex- 
tirpation of  the  granulation-tissue,  can  only  be  accomplished  by  a  radical 
operation.  A  radical  operation  has  for  its  object  the  removal  of  all  of  the 
infected  tissues,  which  means  complete  extirpation  of  the  tendon-sheath  and 
erasion  of  the  granulations  that  have  invaded  the  tendon.  No  operation 
should  be  undertaken  unless  the  surgeon  can  count  with  almost  positive  cer- 
tainty upon  aseptic  healing  of  the  wound.  Infection  with  pus-microbes  un- 
der such  circumstances  would  not  only  prevent  a  satisfactory  functional  re- 
sult, but  would  place  the  patient's  life  in  great  peril.  Fortunately,  this  form 
of  surgical  tuberculosis  attacks  localities  where  the  surgeon  has  it  in  his  power 
to  obtain,  almost  with  absolute  certaintj^,  an  aseptic  healing  of  the  wound. 
Extirpation  of  a  tubercular  tendon-sheath  is  a  tedious  and  difficult  task.  The 
operation  must  be  made  with  the  nicety  of  a  dissection  in  the  anatomical 
room.  A  large  tenotomy-knife  and  a  small  pair  of  curved  scissors  are  the 
most  useful  cutting  instruments  in  making  the  dissection.  A  number  of 
small  tenacula  and  toothed  dissecting-f  orceps  are  necessary  to  retract  tendons 
and  expose  the  parts  fully  to  view.  Esmarch's  constrictor  is  an  indispenable 
aid,  as  it  renders  the  tissues  perfectly  bloodless,  which  enables  the  operator 
to  identify  the  parts  concerned  in  the  dissection.  After  the  aseptic  precau- 
tions have  been  completed  with  the  greatest  care,  the  limb  is  rendered  blood- 
less and  the  tendon-sheath  is  fully  exposed  by  free  external  incision,  which 
should  reach  on  both  sides  a  little  beyond  the  visible  limits  of  the  disease. 
The  tendon-sheath  is  now  slit  open,  and  the  fluid  contents  are  washed  away 
by  an  antiseptic  irrigation. 

In  operating  upon  the  flexor  tendons  of  the  hand  and  fingers  it  often 
becomes  necessary  to  divide  the  annular  ligament,  which  can  be  done  with- 
out fear  of  impairing  the  functional  result,  as,  after  the  operation  on  the 
tendon  has  been  completed,  its  continuity  can  be  restored  by  a  number  of 
separate  buried  sutures.  The  large  arteries  and  nerves  are,  of  course,  care- 
fully avoided.  In  order  to  remove  the  tendon-sheath  completely,  it  becomes 
necessary  to  liberate  the  tendon  and  to  have  it  drawn  out  of  the  way  by  an 
assistant.  The  removal  of  the  deep  portion  of  the  sheath  requires  special 
care,  as  it  often  is  in  close  proximity  to  the  underlying  joint,  which  should 
not  be  opened  unless  the  disease  has  invaded  the  capsule  deeply.  The  ex- 
tension of  the  disease  to  the  muscular  tissue  can  be  readily  ascertained  from 
the  naked-eye  appearances  of  the  muscle,  which,  if  affected,  presents  a  gray- 
ish appearance,  and  is  firmer  than  in  a  normal  condition.  If  the  tendon  is 
extensively  infiltrated  its  size  is  often  much  diminished  by  the  removal  of 
the  infected  portion,  which  must  be  done  with  a  sharp  tenotomy-knife.     If 


TUBEECULAK    TENDO-VAGINITIS.  '  595 

several  tendons  are  affected,  and  access  to  the  more  remote  ones  is  rendered 
impossible  without  division  of  the  more  superficial  tendons,  these  can  be 
divided,  and  again  united  after  the  dissection  has  been  completed.  I  have 
repeatedly  spent  two  hours  in  an  operation  for  tendon  tuberculosis  in  the 
wrist -joint  region,  and  have  always  felt  that  the  time  was  well  spent,  as  a 
hasty  operation  is  often  attended  by  unnecessary  injury  to  contiguous  parts, 
and  is  frequently  followed  by  local  recurrence  on  account  of  incomplete  re- 
moval of  the  infected  tissue.  Should  it  become  necessary  to  resect  a  portion 
of  a  tendon  on  account  of  extensive  disease  of  this  structure,  restoration  of 
continuity  must  be  effected  by  an  autoplastic  operation.  The  tendon-end 
most  suitable  for  this  purpose  is  selected.  The  tendon  is  cut  through  one- 
half  at  a  distance  from  its  cut  end  which  corresponds  with  the  length  of  the 
defect,  when  it  is  split  toward  the  cut  end  to  within  a  few  lines,  and  the 
piece  is  then  laid  over  the  defect  and  sutured  at  both  ends.  After  the  re- 
moval of  the  infected  tissues,  the  wound  is  irrigated  once  more  with  an  anti- 
septic solution,  dried,  and  iodoformized.  The  deep  fascia  is  united  separately 
with  buried  sutures,  and  the  skin  is  coaptated  accurately  with  interrupted 
stitches  and  the  continued  suture.  The  wound  is  either  sutured  throughout 
or  a  catgut  capillary  drain  is  inserted  and  a  copious  antiseptic  dressing  ap- 
plied. The  limb  is  placed  upon  a  well-padded  splint  with  the  fingers  slightly 
flexed,  and,  if  no  indications  for  a  change  of  dressing  arise,  the  first  dress- 
ing is  allowed  to  remain  from  two  to  three  weeks,  when  the  wound  will 
be  found  healed  throughout.  The  functional  result  is  almost  always  satis- 
factory if  the  wound  heals  by  primary  union.  Massage  and  passive  motion 
are  instituted  as  soon  as  the  wound  is  healed.  If  the  operation  is  done  early 
and  with  the  necessary  care,  a  local  recurrence  is  not  to  be  expected.  For 
the  purpose  of  illustrating  the  pathological  conditions  and  the  clinical  tend- 
encies of  this  disease,  I  will  briefly  describe  one  of  the  many  cases  of  tendon- 
sheath  tuberculosis  that  have  come  under  my  observation.  This  case  is  re- 
markable on  account  of  the  rapid  extension  of  the  disease.  The  patient  was 
a  man  60  years  of  age,  laborer,  and  addicted  to  intemperate  habits.  I  ex- 
amined him,  in  consultation  with  his  family  physician,  about  four  months 
before  the  operation  was  performed.  At  that  time  I  found  an  oblong  swell- 
ing on  the  dorsum  of  the  right  hand,  corresponding  to  the  location  of  the 
extensor  tendon  of  the  index  finger.  The  swelling  was  not  painful,  and  but 
little  tender  on  pressure.  Fluctuation  was  well  marked;  on  deep  pressure 
movable  bodies  could  be  distinctly  felt,  which  were  recognized  as  corpora 
oryzoidea.  An  operation  was  advised,  but  was  declined,  as  the  patient  was 
still  able  to  follow  his  occupation.  The  swelling  was  first  noticed  six  weeks 
before  the  examination,  but  steadily  increased  in  size.  Four  months  later  he 
was  admitted  into  the  hospital,  as  the  pain  and  the  size  of  the  swelling  now 
disabled  him  from  performing  manual  labor.     At  this  time  the  dorsum  of 


596  PEINCIPLES    OF    SURGERY. 

the  hand  corresponding  to  the  index  and  middle  fingers  and  tlie  radial  as- 
pect of  the  forearm  as  far  as  the  middle  presented  a  continuous  swelling;, 
with  well-marked  fluctuation.  The  swelling  had  lately  become  painful,  and 
was  tender  on  pressure.  Under  strict  aseptic  precautions  the  swelling  was 
incised  in  its  entire  length,  and  a  large  quantity  of  synovia-like  fluid  and 
softened  rice-bodies  escaped.  The  sheaths  of  the  extensor  communis  dig- 
itorum  and  extensors  of  the  wrist  were  found  lined  with  a  thick  layer  of 
fungous  granulations,  and  near  the  annular  ligament  numerous  free  and 
attached  rice-bodies  were  found.  The  tendon-sheaths  were  carefully  dis- 
sected out,  and  the  whole  wound,  after  thorough  disinfection,  was  dusted 
with  iodoform,  drained,  and  sutured.  A  copious  dressing  of  iodoform  gauze 
and  sublimated  moss  was  applied,  and  the  forearm  and  hand  fixed  upon  an 
anterior  splint.  Healing  of  the  wound  by  primary  intention.  Almost  com- 
plete restoration  of  function.  No  return  after  two  years,  and  patient  able 
to  perform  hard  manual  labor.  Inoculations  of  the  fluid  upon  potato  re- 
mained sterile.  Cultivation  upon  coagulated  hydrocele-serum  showed,  after 
a  few  weeks,  a  scanty  culture  of  the  bacillus  of  tuberculosis.  Implantation 
of  one  of  the  rice-bodies  into  the  subcutaneous  connective  tissue  of  a  guinea- 
pig  resulted  in  a  typical  tuberculosis,  starting  from  the  point  of  inoculation, 
spreading  to  adjacent  lymphatic  glands,  and  finally  resulting,  in  six  weeks, 
in  death  from  diffuse  miliary  tuberculosis. 

TUBEECULOSIS    OF    MUSCLES. 

This  affection  was  first  described  by  Zenker  in  1870,  but  in  all  of  the 
cases,  5  in  number,  published  by  Oltendorf  in  1885,  it  had  extended  by  con- 
tiguity from  an  adjacent  organ.  Similar  cases  were  observed  later  by  G-enz- 
mer,  Marchand,  Eapp,  Bidder,  and  others.  Latour  saw  a  case  of  tubercular 
abscess  of  the  external  radial  muscles  and  of  the  deltoid,  and  Denonvilliers 
found  ah  isolated  tubercular  abscess  in  the  biceps  muscle.  Habermaas  first 
described  muscle  tuberculosis  as  a  primary  affection.  Mtiller  reported  a 
similar  case  from  the  clinic  at  Tubingen.  The  swelling  in  this  case  in- 
volved the  quadriceps  muscle.  Delorme  gave  a  description  of  four  cases  of 
primary  tuberculosis  of  muscles  at  the  fifth  meeting  of  the  French  Congress 
of  Surgeons.  J.  L.  Reverdin  observed  a  case  of  primary  tuberculosis  of  the 
triceps  muscle.  Mendez  records  2  cases  of  tuberculosis  of  the  heart-muscle, 
and  refers  to  39  cases  collected  from  literature.  The  first  thorough  descrip- 
tion of  primary  muscle  tuberculosis  was  given  by  Lanz  and  de  Quervain, 
based  on  the  clinical  history  and  microscopical  examinations  of  8  cases.  They 
made  careful  histological  and  bacteriological  investigations,  with  a  full  de- 
scription of  the  diagnosis,  prognosis,  and  treatment  of  this  affection.  The 
results  of  their  observations  appear  to  prove  that  this  form  of  tuberculosis 
is  amenable  to  successful  treatment  by  thorough  excision. 


FASCIA   TUBEECULOSIS.  597 


FASCIA   TUBEECULOSIS. 


The  bacillus  of  tuberculosis  has  a  special  predilection  for  fascia,  and 
primary  localization  in  this  tissue  is  a  frequent  occurrence.  It  is  a  well- 
known  clinical  fact  that,  as  soon  as  a  deep  tubercular  focus  in  a  lymphatic 
gland,  bones,  or  joints  has  reached  the  connective  tissue  outside  of  the  organ 
primarily  affected,  the  infection  travels  along  the  connective  tissue,  often 
resulting  in  quite  extensive  destruction  of  this  tissue  before  the  process 
reaches  the  surface.  The  extension  of  tubercular  abscesses  along  preformed 
connective-tissue  spaces  has  been  previously  described.  If  the  tubercular 
product,  when  it  reaches  the  loose  connective  tissue,  is  composed  of  living 
embryonal  tissue,  the  pathological  lesions  that  are  later  produced  in  the  con- 
nective tissue  correspond  with  those  of  the  primary  lesion.  The  connective 
tissue  is  transformed  into  masses  of  granulation-tissue,  which  remain  in  this 
state  for  a  long  time  before  it  is  destroyed  by  coagulation-necrosis,  with  sub- 
sequent cell-disintegration.  In  primary  tuberculosis  of  the  fascia  the  dis- 
ease often  spreads  with  great  rapidity,  dipping  down  between  the  muscles 
along  the  intermuscular  septa,  and  invading  from  here  the  muscles  them- 
selves. I  have  seen  a  number  of  cases  during  the  last  few  years  where  the 
disease  originated  primarily  in  the  deep  fascia  of  the  thigh,  resulting  in  the 
most  extensive  regional  dissemination  in  the  course  of  two  or  three  years. 
In  one  case,  a  veteran  of  the  late  war,  55  years  of  age,  the  disease  commenced 
at  a  point  between  the  greater  trochanter  and  the  crest  of  the  ilium  several 
years  before  he  came  under  my  observation.  I  found  the  thigh  moderately 
swollen  with  several  prominences  from  the  crest  of  the  ilium  to  the  knee- 
joint,  where  fluctuation  was  quite  distinct.  I  mistrusted  a  primary  osteo- 
tuberculosis,  but,  on  making  free  incisions  at  different  points,  I  found  no 
evidence  of  primary  tuberculosis  of  any  other  tissue  or  organ.  The  deep 
fascia  and  intermuscular  septa  were  found  destroyed,  and  in  their  place 
masses  of  granulation-tissue  presenting  foci  of  coagulation-necrosis  and 
caseation  invading  extensively  the  muscular  tissue.  Volkmann's  spoon 
was  freely  used,  but  I  soon  found  that  this  treatment  was  utterly  inade- 
quate to  remove  all  the  infected  tissue,  as  the  deep  muscles  throughout 
were  extensively  infiltrated.  Amputation  was  out  of  the  question,  as  the 
gluteal  region  as  far  as  the  crest  of  the  ilium  was  so  extensively  affected 
that  it  would  have  been  impossible  to  obtain  a  covering  for  a  hip-joint  am- 
putation, lodoformization  of  the  enormous  spaces  made  by  scraping  out 
the  fungous  granulations  had  no  effect  in  arresting  farther  extension  of  the 
disease.  The  patient  died,  three  months  later,  of  general  miliary  tuber- 
culosis. 

In  a  second  somewhat  parallel  case  the  disease  extended  from  near  the 
knee-joint  as  far  as  the  trochanter  minor.     This  patient  was  only  25  5^ears 


598  PEINCIPLES    OF    SUEGERY. 

of  age,  and  the  disease  had  existed  a  year  and  a  half.  Several  incisions  had 
been  made,  and  a  number  of  fistulous  openings  were  found  in  communica- 
tions with  large  cavities  between  the  deep  muscles  of  the  thigh.  The  sinuses 
were  laid  open  and  scraped,  and  the  most  careful  examijiation  failed  in  dis- 
closing a  primary  osteal  or  tendon-sheath  tuberculosis.  The  muscles  were 
again  found  extensively  infiltrated  and  of  a  grayish-white  color,  and  almost 
of  gristly  hardness  on  being  incised.  The  operation  rather  hastened  than 
retarded  the  progress  of  the  disease,  and  I  was  forced,  a  few  weeks  later,  to 
amputate  the  thigh  just  below  the  trochanters.  The  patient  made  a  slow 
recovery,  but  remained  in  fair  health  two  years  after  the  operation  without 
any  indications  of  a  local  recurrence.  I  have  learned  to  regard  fascia  tuber- 
culosis affecting  the  intermuscular  septa  of  the  thigh  as  an  exceedingly 
grave  form  of  local  tuberculosis,  and,  if  at  all  extensive,  only  amenable  to 
successful  treatment  by  amputation. 

TUBERCULOSIS  OF  MOUTH  AND  TONGUE. 

We  have  now  every  reason  to  believe  that  many  cases  of  ulceration  of 
the  tongue,  pharynx,  and  cavity  of  the  mouth,  which  have  been  heretofore 
diagnosticated  and  treated  as  carcinoma,  were  not  carcinoma,  but  syphilis 
or  tuberculosis.  Professor  von  Esmarch,  in  a  very  able  paper,  a  few  years 
ago  called  attention  to  the  difficulties  in  the  way  in  differentiating  between 
these  affections.  Out  of  114  cases  of  buccal  tuberculosis  collected  by  Dela- 
van,  in  1886,  only  two  were  on  the  lip.  Mackenzie,  of  Edinburgh,  refers  to 
a  third;  a  fourth  was  seen  in  Vienna,  but  not  reported;  and  Welch,  of  Balti- 
more, had  met  with  a  fifth.  There  can  be  but  little  doubt  that  many  similar 
eases  have  been  mistaken  for  carcinoma. 

Zaudy  has  studied  tuberculosis  of  the  alveolar  process.  He  states  that 
the  bacilli  enter  between  the  gingiva  and  teeth.  Caries  acts  as  a  predispos- 
ing cause.  The  disease  is  most  common  in  persons  between  15  and  50  years 
of  age  and  is  more  frequent  in  the  male  than  the  female;  thus,  in  37  cases  23 
were  men. 

Pathology. — There  is  no  doubt  that  many  reported  cases  of  permanent 
recovery,  after  removal  by  operation  of  ulcerating  swellings  of  the  tongue, 
were  not  cases  of  carcinoma,  but  tuberculosis.  Lupus  of  the  pharynx  and 
tongue  are  cases  of  local  tuberculosis.  Some  time  ago  I  had  an  opportunity 
to  examine  a  case  of  primary  tuberculosis  of  the  phar5mx  occurring  in  a  man 
30  years  of  age.  The  disease  had  existed  for  four  months,  and  involved  the 
posterior  wall  of  the  pharynx,  and  had  extended  to  the  left  tonsil.  Eagged, 
deep  ulcers  had  formed,  which  were  covered  with  flabby,  yellowish-gray 
granulations.  Numerous  minute  miliar}''  nodules  could  be  seen  in  the  mu- 
cous membrane  around  the  ulcers,  and  on  scraping  away  the  granulations 
they  were  also  found  present  in  the  softened,  inflamed  tissues  imderneath  the 


TUBEKCULOSIS  OF  MOUTH  AND  TONGUE.  599 

floor  of  the  ulcers.  A  beginning  hoarseness  indicated  that  the  disease  was 
extending  by  continuity  of  tissue  to  the  larynx.  Laryngoseopical  examina- 
tion revealed  numerous  minute  nodules,  which  studded  the  mucous  mem- 
brane of  the  posterior  surface  of  the  epiglottis.  The  recent  advances  made 
in  the  microscopical,  bacteriological,  and  experimental  methods  of  examina- 
tion have  succeeded  in  separating  from  syphilitic  affections  and  malignant 
disease  of  the  mouth  and  tongue  many  cases  that  belong  to  the  long  list  of 
affections  now  classified  under  the  head  of  surgical  tuberculosis.  The  cavity 
of  the  mouth  is  often  the  seat  of  slight  abrasions  and  pathological  conditions, 
which  may  become  an  infection-atrium  for  the  entrance  of  microorganisms 
that  might  be  contained  in  the  air  we  breathe,  the  food  we  eat,  and  the  water 
we  drink.  Eemembering  the  frequency  with  which  superficial  abrasions  and 
ulcerations  occur  in  this  locality,  it  is  not  strange  that  primary  tuberculosis 
should  occasionally  develop  here.  The  tubercle  bacillus  produces  the  same 
tissue-changes  here  as  on  the  surface  of  the  skin,  the  primary  pathological 
product  consisting  of  granulation-tissue  undergoing  molecular  retrograde 
tissue  metamorphosis,  followed  by  ulceration.  Ulceration  is  an  earlier  oc- 
currence and  a  more  conspicuous  clinical  feature  in  tuberculosis  of  the 
mouth  than  in  some  other  localities,  as  the  new  tissue  is  constantly  macerated 
by  the  fluids  with  which  it  is  moistened  at  all  times.  The  tubercular  ulcer 
is  generally  covered  by  the  products  of  interstitial  necrobiosis  and  superficial 
coagulation-necrosis,  which  result  in  the  formation  of  what  appears  as  a  false 
membrane.  If  this  membrane,  when  present,  is  removed,  the  characteristic 
granulation-surface  is  exposed.  The  ulcer  is  surrounded  by  a  zone  of  in- 
flammatory infiltration,  which,  however,  does  not  present  the  same  feeling  of 
hardness  as  carcinoma.  The  most  characteristic  feature  of  a  tubercular  ulcer 
of  the  mouth  or  tongue  consists  in  the  presence  of  minute  tubercle-nodules 
in  the  margins  and  underneath  the  layer  of  granulations,  and,  if  the  infec- 
tion has  extended  to  some  distance,  in  the  surrounding  mucous  membrane. 
Schliferowitsch  has  published  an  exhaustive  resume  of  the  literature  on  this 
subject,  and  has  collected  all  the  recorded  cases  in  which  the  diagnosis  of 
tubercular  disease  of  the  cavity  of  the  mouth  could  be  made  with  some  degree 
of  certainty.  The  cases  number  88,  and  include  those  of  primary  and  sec- 
ondary tuberculosis.  From  a  careful  study  of  this  affection  he  has  come  to 
the  conclusion  that  it  occurs  seldom  in  the  very  young,  and  that  it  attacks 
most  frequently  persons  between  40  and  50  years  of  age. 

Symptoms  and  Diagnosis. — Tuberculosis  of  the  mucous  membrane  of 
the  cavity  of  the  mouth  appears  as  a  flattened,  submucous  infiltration  com- 
posed of  granulation-tissue,  which,  at  an  early  date,  becomes  the  seat  of  a 
superficial  ulceration  in  the  centre  that  rapidly  extends  toward  the  margins 
of  the  swelling.  Caseation  is  seldom  observed.  The  cells  are  destroyed  by 
coagulation-necrosis,  and  as  they  become  detached  the  defect  increases  in 


600  PKINCIPLES    OF    SUEGERY, 

size.  The  appearance  of  the  ulcer  in  this  locality  is  characteristic.  If  on 
the  tonguC;,  it  is  found  on  the  borders  near  the  tip  of  the  organ.  It  appears 
as  an  oblong  ulcer,  with  raised,  ragged  borders  of  firmer  consistence,  show- 
ing the  color  of  fresh  granulations.  The  ulcer  often  appears  as  if  covered  by 
a  pseudomembrane;  if  this  covering  is  removed  the  surface  left  easily  bleeds. 
The  surface  of  the  ulcer  is  uneven,  as  if  covered  with  hypertrophic  papillae. 
The  discharge  of  pus  is  slight,  and,  in  many  cases,  miliary  nodules  may  be 
found  around  the  ulcer.  Pain  is  not  as  severe  as  in  carcinoma.  Lymphatic 
glands  may  become  secondarily  infected,  but  this  is  not  often  the  case.  In 
the  primary  form  of  the  disease,  when  a  positive  diagnosis  is  most  difficult, 
the  presence  of  tubercle  bacilli  will  demonstrate  the  nature  of  the  ulcer.  A 
gumma  of  the  tongue,  as  a  rule,  develops  into  a  larger  swelling  than  a  tuber- 
cular affection  before  ulceration  takes  place,  and  the  resulting  ulcer  is  more 
deeply  excavated;  at  the  same  time,  other  evidences  of  syphilis  can  usually 
be  detected.  Miliary  nodules  in  the  immediate  vicinity  of  the  ulcer  are 
absent  in  a  syphilitic  ulcer,  and  frequently  present  in  tuberculosis.  If  any 
ddubt  remain  as  to  the  difEerential  diagnosis  between  these  two  affections, 
this  should  be  set  aside  by  a  course  of  antisyphilitic  treatment  before  resort- 
ing to  any  serious  operation.  If  the  ulcer  is  syphilitic  it  will  heal  kindly 
under  such  treatment,  while  no  improvement  will  be  noticeable  if  it  is  tuber- 
cular. Epithelioma  commences  as  a  superficial  infiltration  and  penetrates 
the  tissues  from  without  inward.  Induration  around  and  underneath  the 
ulcer  is  more  marked  in  an  ulcerating  epithelioma  than  in  a  tubercular  ulcer. 
Glandular  infection  takes  place  early,  and  is  almost  a  constant  occurrence  in 
epithelioma,  but  is  seldom  observed  in  the  course  of  a  tubercular  ulcer.  In 
a  case  of  primary  tuberculosis  of  the  tonsils  that  recently  came  under  the  ob- 
servation of  the  writer  the  deep  glands  of  the  neck  were  extensively  involved, 
and  an  examination  of  the  tonsils  after  their  removal  showed  that  they  were 
the  seat  of  early  and  extensive  caseation.  A  simple  ulcer  of  the  tongue 
caused  by  the  mechanical  irritation  from  a  sharp  projection  of  a  carious  or 
displaced  tooth  can  be  readily  recognized  by  the  location  and  character  of  the 
ulcer.  Such  an  ulcer  may  become  the  seat  of  a  tubercular  ulcer  or  the  start- 
ing-point of  an  epithelioma. 

Treatment.- — The  local  treatment  of  a  tubercular  ulcer  of  the  mouth  or 
tongue  is  the  same  as  when  a  similar  ulcer  is  located  upon  the  surface  of  the 
body.  If  the  lesion  is  circumscribed  sufficiently  that  the  wound,  after  com- 
plete excision,  can  be  closed  by  suturing,  this  method  of  treatment  should 
be  adopted,  as  it  is  certainly  the  most  radical,  and  results  most  speedily  in 
complete  recovery.  If  the  extent  of  the  disease  render  this  treatment  in- 
applicable, the  diseased  tissues  should  be  removed  as  thoroughly  as  possible 
by  a  vigorous  use  of  the  sharp  spoon,  or  by  destroying  it  with  the  actual 
cautery,  or  both  of  these  measures  may  be  combined.    The  use  of  superficial 


TUBERCULOSIS    OF    THE    INTESTINES.  601 

caustics  has  a  tendency  rather  to  aggravate  the  disease  than  to  cure  it.  With 
a  sharp  spoon  all  of  the  soft  tissues  are  scraped  away,  the  healthy  tissue  heing 
recognized  by  its  greater  firmness  and  resistance  to  the  spoon.  After  bleed- 
ing has  ceased  the  surface  is  cauterized  with  the  flat  point  of  a  Paquelin  cau- 
tery, and,  if  the  disease  has  dipped  in  farther  at  certain  points,  these  are 
attacked  by  making  ignipuncture  with  the  needle-point  of  the  Paquelin  cau- 
tery. The  cavity  of  the  mouth,  during  the  after-treatment,  must  be  kept  as 
nearly  as  possible  in  an  aseptic  condition  by  dusting  the  surface  daily  with 
iodoform,  and  by  the  frequent  use  of  a  mild,  antiseptic  mouth-wash,  such  as 
a  saturated  solution  of  acetate  of  aluminum  or  boric  acid.  If  all  the  infected 
tissues  have  been  destroyed,  healing  takes  place  rapidly  by  granulation,  cica- 
trization, and  epidermization  after  separation  of  the  eschar.  If  any  of  the 
infected  tissues  have  remained,  the  process  of  healing  is  retarded  or  com- 
pletely arrested;  in  the  latter  event  a  repetition  of  the  same  local  treatment 
will  become  necessary. 

TUBEECULOSIS    OF   THE    STOMACH. 

There  is  reason  to  believe  that  tuberculosis  of  the  mucous  membrane 
of  the  healthy  stomach  does  not  occur.  Tubercular  infection  of  the  stomach, 
however,  can  occur  if  the  mucous  membrane  and  the  secretions  are  so  altered 
that  the  resistance  to  the  tubercle  bacillus  is  lost.  Very  few  well-authen- 
ticated cases  of  tuberculosis  of  the  stomach  have  been  reported.  Orlandi 
records  a  case  of  primary  tuberculosis  of  the  stomach  in  a  man  20  years  of 
age.  Of  18  cases  so  far  reported,  14  were  males,  and  among  this  number  in  6 
the  ulcers  were  on  the  lesser  curvature,  4  near  the  pyloric  end,  and  in  4 
widely  distributed  over  the  surface  of  the  mucous  membrane.  Of  24  cases, 
isolated  ulcers  were  found  in  12  and  in  the  remaining  12  the  ulcers  were 
multiple. 

TUBEECULOSIS    OF   THE   INTESTINES. 

Primary  tuberculosis  of  the  intestinal  mucous  membrane  is  a  compara- 
tively frequent  affection,  but  becomes  a  surgical  lesion  only  in  case  it  leads 
to  intestinal  obstruction  or  perforation.  If,  as  is  sometimes  the  case,  the 
infection  is  limited  to  a  single  focus,  a  timely  operation  not  only  relieves  the 
symptoms  which  made  surgical  treatment  a  necessity,  but  it  may  result  in 
a  permanent  cure.  The  tubercular  lesions  of  the  intestinal  mucous  mem- 
brane that  occasionally  indicate  treatment  by  laparotomy  are  usually  found 
in  the  lower  portion  of  the  ileum,  the  ileo-csecal  region,  c^cum,  or  ascending 
colon.  Tubercular  inflammation  of  the  large  intestine  may  cause  so  much 
swelling  as  to  give  rise  to  intestinal  obstruction.  When  the  inflammatory 
process  is  limited  to  a  small  portion  of  the  bowel,  operative  removal  of  the 
afEected  segment  is  justifiable  and  holds  out  a  fair  prospect  of  permanent  re- 


603  PEINCIPLES    OF    SUEGEEY. 

lief.  Schier  reports  a  successful  case  of  this  kind.  At  the  close  of  October;, 
1887,  he  was  consulted  by  a  man  who  had  a  painful  swelling  in  the  right 
hypochondrium;  the  swelling  was  as  large  as  a  man's  fist,  with  a  nodular 
surface.  Considerable  pain,  tenderness,  emaciation,  and  evidences  of  intes- 
tinal obstruction,  which  were  gradually  increasing  in  intensity.  A  tumor 
of  the  caecum  was  diagnosticated,  and  laparotomy  was  performed  Novem- 
ber 1st  of  the  same  year.  The  abdomen  was  opened  by  a  lateral  incision. 
The  omentum  near  the  swelling  was  much  inflamed  and  covered  with 
whitish-yellow  nodules,  from  the  size  of  a  pin  to  that  of  a  pea.  Twelve  to 
sixteen  enlarged  glands,  some  as  large  as  a  walnut,  situated  along  the 
vertebral  column,  were  enucleated  or  removed  with  a  sharp  spoon.  The 
csecum  was  so  fragile  that  it  ruptured  during  the  manipulations  and  some 
faeces  escaped.  The  bowel  above  and  below  the  swelling,  which  involved 
the  cgecum,  was  emptied  by  expression,  tied  with  rubber  bands,  and  the 
affected  portion  excised.  The  part  of  the  csecum  containing  the  valve  and 
the  vermiform  appendix  was  left.  Circular  suturing  by  a  double  row  of 
sutures.  The  subsequent  history  of  the  case  was  favorable  in  every  re- 
spect. Pain  was  severe  for  two  days,  and  yielded  to  large  doses  of  opium. 
Eighteen  months  after  the  operation  the  patient  remained  in  good  health. 
Examination  of  the  part  removed  showed  that  the  swelling  was  of  a  tuber- 
cular nature,  the  submucosa  and  external  layers  of  the  bowel  being  mainly 
involved. 

Durante  reported  a  somewhat  similar  case.  The  patient  was  a  woman, 
aged  56,  who,  for  four  or  five  years,  had  suffered  from  obscure  pain  in 
the  right  iliac  fossa  when  at  stool.  The  pain  increased  in  intensity  and 
became  paroxysmal,  and  the  patient  almost  starved  herself,  with  the  object 
of  avoiding  the  torture  of  defecation.  On  examination  a  tumor  was  found 
in  the  right  iliac  fossa,  extending  downward  toward  the  upper  outlet  of 
the  pelvis.  Carcinoma  of  the  csecum  or  neighboring  parts  was  suspected. 
The  abdomen  was  opened.  The  swelling,  as  large  as  a  lemon,  was  found 
adherent  to  the  iliac  fossa,  the  parietal  peritoneum  and  coils  of  the  small 
intestine  being  matted  to  it  so  firmly  that  the  lower  end  of  the  latter, 
measuring  25  centimetres  in  length,  together  with  the  caecum  and  a  por- 
tion of  the  ascending  colon,  was  removed  with  it.  The  two  ends  of  the 
divided  intestine  were  brought  together  by  three  rows  of  sutures.  The 
abdominal  wound  was  closed,  and  the  patient  made  a  rapid  and  perma- 
nent recovery.  The  swelling,  which  had  almost  completely  blocked  up  the 
lumen  of  the  intestine,  was  found  to  be  of  a  tubercular  nature.  Since 
these  cases  were  reported,  a  number  of  successful  operations  have  been  per- 
formed for  tuberculosis  of  the  csecum.  If,  in  cases  of  intestinal  tubercu- 
losis indicating  laparotomy,  it  should  be  found,  after  opening  the  abdo- 
men, that  the  foci  in  the  ileo-c^cal  region  are  too  numerous  to  warrant  a 


TUBEKCrLOSIS    OF    THE    MAMMAEY    GLAND.  603 

radical  operation  by  enterectomy,  the  symptoms  can  be  relieved  and  the 
inflamed  parts  excluded  from  the  faecal  circulation  by  establishing  an  anas- 
tomosis between  the  intestine  above  and  below  the  affected  segment. 

TUBEKCULOSIS   OF  THE  MAMMARY  GLAND. 

A  large  number  of  well-authenticated  cases  of  primary  tuberculosis 
of  the  mammary  gland  have  been  reported.  So  far  as  the  infection  is 
concerned,  the  breast  must  be  considered  as  an  appendage  of  the  skin. 
The  bacillus  from  without  may  effect  entrance  into  the  gland  through 
the  milk-ducts,  in  which  case  the  inflammatory  process  commences  in 
the  parenchyma  of  the  gland;  or  it  may  enter  through  a  fissure  of  the 
nipple,  in  which  case  the  process  is  primarily  interstitial.  When  direct 
infection  from  without  can  be  excluded,  the  disease  is  the  result  of  auto- 
infection,  and  on  this  account  the  prognosis  is  always  more  unfavor- 
a,ble.  In  reference  to  the  manner  of  local  infection  Mandry  distinguishes 
two  forms  of  primary  tuberculosis  of  this  gland.  The  first  is  very  chronic, 
in  which  the  tubercular  j)roduct  is  circumscribed,  appearing  as  a  firm 
nodular  mass,  which  later  undergoes  caseation.  Abscesses,  fistulse,  re- 
traction of  the  nipple,  and  secondary  infection  of  the  axillary  glands 
appear  in  the  course  of  years.  The  second  form  is,  from  the  beginning, 
more  diffuse  and  resembles  clinically  a  cold  intramammary  abscess.  The 
disease  is  met  with  most  frequently  in  women  who  are  nursing,  but  I  have 
repeatedly  observed  it  in  young  unmarried  women.  Mandry  has  observed 
7  cases  and  describes  21  others  recorded.  One  of  the  28  was  in  a  male 
patient.  Eegional  dissemination  takes  place  along  the  chain  of  axillary 
lymphatic  glands.  Orthmann  examined  the  enlarged  lymphatic  glands 
in  a  case  of  primary  tuberculosis  of  the  mamma,  and  found  numerous 
tubercle  bacilli.  The  disease  is  differentiated  from  carcinoma  by  the 
absence  of  jDain  and  hardness  in  the  swelling  and  from  an  ordinary  sup- 
purative mastitis  by  the  absence  of  the  prominent  symptoms  of  acute 
inflammation.  It  might  be  mistaken  for  a  lacteal  cyst  or  an  echinococcic 
cyst,  but  all  doubt  as  to  the  nature  of  the  swelling  can  be  set  aside  by  an 
exploratory  puncture. 

Treatment. — The  more  expectant  plans  of  treatment  recommended 
in  the  management  of  tubercular  abscesses  communicating  with  the 
primary  foci  in  tissues  and  organs  deeply  situated  should  not  be  fol- 
lowed in  the  treatment  of  tubercular  affections  of  the  breast,  as  in  these 
cases  a  radical  operation  is  not  attended  by  any  danger  to  life,  and  usually 
results  in  a  permanent  cure.  The  plan  to  be  pursued  depends  on  the 
extent  and  location  of  the  disease.  A  superficial  limited  tubercular  focus 
of  the  mamma  can  be  successfully  treated  by  excising  the  infected  tissues. 
If  the  process  is  more  deeply  located,  it  may  become  necessary  to  remove 


604  PRINCIPLES    OF    SURGERY. 

a  portion  of  the  mammary  gland  with  it.  Partial  excision  of  the  gland 
should  be  done  in  such  a  manner  as  to  include  the  tubercular  focus  in  a 
wedge-shaped  section  of  the  gland,  the  base  of  the  wedge  being  directed 
toward  the  periphery  of  the  gland.  After  excision  the  cut  surfaces  of  the 
gland  are  united  with  buried  catgut  sutures.  If  the  disease  has  infiltrated 
the  gland  extensively,  or  if  a  number  of  sinuses  or  abscesses  have  formed,  it 
becomes  necessary  to  extirpate  the  entire  gland.  Enlarged  glands  are  re- 
moved in  the  same  thorough  manner  as  in  operating  for  carcinoma  of  the 
breast.    Multiple  foci  necessitate  excision  of  the  entire  gland. 

TUBERCULOSIS    OF   THE   GENITO-URINARY    ORGANS. 

It  is  only  within  the  last  few  years  that  a  number  of  chronic  inflam- 
matory processes  of  the  genito-urinary  organs  in  both  sexes  have  been 
shown  to  be  tubercular  in  their  origin,  clinical  tendencies,  and  final  ter- 
mination. The  susceptibility  of  the  mucous  membrane  of  the  genito- 
urinary tract  to  tubercular  infection  has  been  demonstrated  experiment- 
ally by  Cornet.  In  rubbing  a  pure  culture  of  tubercle  bacilli  in  superficial 
abrasions  of  the  penis  in  dogs  he  produced  a  tubercular  lesion  of  that 
organ.  In  bitches  tuberculosis  of  the  vagina  and  uterus  could  be  pro- 
duced by  injections  of  a  pure  culture  into  the  vagina.  The  local  lesions 
were  followed  by  general  tuberculosis. 

(a)  Tuberculosis  of  Vulva,  Vagina,  and  TJtenis. — Direct  tubercular 
infection  of  the  genital  tract  in  women  has  been  observed,  but  the  cases 
so  far  reported  are  few.  Eobitansky  believed  that  tuberculosis  of  the 
cervix  uteri  is  always  limited,  while  Lebert  denied  its  existence.  Paulson 
describes  it  as  a  tubercular  erosion  of  the  cervical  canal,  and  says  it  never 
invades  the  vaginal  portion  of  the  cervix.  Hosier  found  the  uterus 
affected  in  4  out  of  46  post-mortems  made  upon  women  who  had  died  of 
tuberculosis.  Kolb  and  Hegar  give  similar  results.  With  the  exception 
of  Friedlander,  authors  are  inclined  to  hold  that  it  usually  occurs  as  a 
secondary  affection.  Barbier  believes  that  a  woman  can  be  infected  by  a 
tubercular  husband  during  coitus,  as  bacilli  have  been  demonstrated  in 
the  semen  of  tubercular  patients,  as  well  as  in  the  discharge  attending 
tubercular  epididymitis.  The  uterus  may  be  infected  by  extension  from 
a  tubercular  lesion  of  the  vulva  without  any  intermediate  trace  of  infec- 
tion in  the  vagina.  The  author  even  admits  the  possibility  that  tuber- 
cular infection  may  be  transmitted  by  the  finger  of  the  attendant,  by  in- 
fected instruments,  or  even  through  the  medium  of  the  air.  Zweigbaum 
reports  a  case  of  primary  tuberculosis  of  the  portio  vaginalis  uteri  which, 
at  the  time  of  examination,  appeared  in  the  shape  of  an  ulcer  the  size  of 
a  walnut,  with  thick,  indurated  margins  and  cheesy  floor.  Numerous 
tubercle  bacilli  were  found  in  the  secretion  taken  from  the  surface  of  the 


TUBERCULOSIS    OF   THE    GENITO-URINARY    ORGANS.  605 

ulcer.     Evidences  of  tuberculosis  were  apjDarent  at  this  time.     After  a  few 
weeks  the  ulcer  extended  toward  the  left  vaginal  wall.    A  section  of  a  frag- 
ment of  tissue  removed  from  these  parts,  on  staining,  showed  numerous  ba- 
cilli.   This  form  of  tuberculosis  is  not  frequent,  as  the  author  could  only  find 
2  cases  of  vulvar  tuberculosis  in  literature,  although  genital  tuberculosis  is 
quite  a  frequent  affection.    Jonin  believes  that  tubercular  endometritis  from 
local  infection  is  quite  a  common  affection.    Of  9  cases  which  were  observed 
by  him  it  was  due  to  sexual  contact  with  men  suffering  from  genital  tubercu- 
losis.   In  2  others  the  husbands  were  tubercular,  but  had  no  genital  tubercu- 
losis.    He  calls  attention  to  the  fact  that  Cornil  and  Chantemesse  have 
produced  this  disease  artificially  in  rabbits  by  injecting  bacilli  into  the 
vagina.    Treub  reports  the  case  of  a  girl  who  had  undergone  all  kinds  of 
treatment,  and  finally  had  the  uterus  scraped  out.     The  appendages  then 
appeared  to  be  perfectly  normal.     On  microscopical  examination  the  por- 
tions of  endometrium  removed  by  the  curette  were  found  to  be  tubercular. 
Two  weeks  later  the  patient  came  under  Treub's  care.     It  was  then  un- 
certain whether  the  tubes  were  affected.     For  six  weeks  she  was  treated 
by  diet  alone,  and  at  the  end  of  that  time  the  tubes  could  be  felt,  forming 
sausage-shaped  swellings  adherent  to  neighboring  parts.    The  uterus  and 
tubes  were  removed  through  the  vagina,  and  at  the  operation  the  peri- 
toneum in  Douglas's  pouch  and  the  serous  coat  of  the  uterus  were  found 
covered  with  tubercles.    A  year  and  a  half  after  the  operation  the  patient 
was  in  perfect  health.     The  cases  of  primary  tuberculosis  of  the  vulva, 
vagina,  and  uterus  will  undoubtedly  become  more  numerous  in  the  litera- 
ture of  the  near  future,  when  improved  methods   of  examination  will 
enable  the  surgeon  to  make  a  positive  diagnosis  between  these  affections 
and  carcinoma  and  syphilitic  lesions.     The  same  points  in  differential 
diagnosis  are  to  be  remembered  in  this  connection  as  have  been  enumer- 
ated in  the  consideration  of  tubercular  affections  of  the  mouth. 

Treatment. — Primary  tuberculosis  of  the  utero-vaginal  canal  and 
vulva  should  be  treated  by  curetting,  and,  if  the  extent  of  the  lesions 
make  it  necessary,  by  cauterization  with  the  actual  cautery.  Before 
either  of  these  procedures  is  put  into  practice  the  parts  must  be  rendered 
aseptic  by  antiseptic  irrigation.  Subsequent  infection  can  be  guarded 
against  by  the  free  use  of  iodoform,  and  tamponade  of  the  vagina  with 
iodoform  gauze.  Under  ordinary  circumstances  it  is  not  necessary  to 
remove  the  tampon  oftener  than  once  a  week,  when  the  surface  is  again 
freely  dusted  with  iodoform  before  a  new  tampon  is  inserted. 

(b)  Tuberculosis  of  Fallopian  Tubes.  —  In  the  absence  of  tubercular 
lesions  of  the  vagina  and  uterus,  it  is  doubtful  if  infection  of  the  Fallopian 
tubes  can  take  place  by  the  entrance  of  the  bacillus  through  the  genital 
tract,  and  the  relatively  frequent  occurrence  of  the  disease  in  that  part 


606  PEINCIPLES    OF    SURGERY. 

of  the  genital  tract  is  only  explainable  by  attributing  it  to  autoinf  ection, 
in  the  same  way  as  we  have  explained  the  occurrence^  for  instance,  of  pri- 
mary tuberculosis  of  joints,  bone,  and  peritoneum.  We  can  safely  assert 
that  tubercular  infection  of  the  Fallopian  tubes  often,  if  not  always,  takes 
place  upon  the  basis  of  preexisting  pathological  conditions,  taking  it  for 
granted  that  the  healthy  tubes  do  not  present  favorable  conditions  for 
the  localization  of  the  tubercle  bacilli.  A  catarrhal  condition  of  the 
mucous  membrane  lining  the  tubes,  as  in  other  organs,  undoubtedly  fur- 
nishes, in  many  instances,  the  locus  minoris  resistentice  for  the  localization 
of  bacilli  brought  to  the  part  through  the  circulating  blood  or  by  infec- 
tion from  without.  Orthmann  states  that  primary  tubal  tuberculosis 
occurs  in  18  per  cent,  of  all  cases  of  tuberculosis  of  the  female  genital 
tract. 

An  interesting  case  of  primary  tuberculosis  of  the  Fallopian  tubes 
has  been  recorded  by  Kotschau.  The  patient  was  45  years  old,  having 
a  good  family  history;  has  suffered  for  a  year  with  pains  in  the  abdomen, 
profuse  metrorrhagia,  and  various  nervous  disturbances.  She  was  treated 
for  retroflexion,  and  subsequently  had  an  attack  of  pelveo-peritonitis. 
Vaginal  examination  disclosed  a  firm,  smooth,  movable  swelling,  as  large 
as  an  apple,  to  the  right  of  the  uterus;  this  was  taken  for  a  malignant 
ovarian  growth,  and  laparotomy  was  done  for  its  removal.  On  opening 
the  abdominal  cavity  a  quantity  of  turbid,  purulent  fluid  escaped.  The 
swelling,  of  oblong  shape,  was  found  lying  apparently  in  a  bed  of  pus; 
on  account  of  its  intimate  adhesions  it  could  not  be  removed.  The  pa- 
tient died  from  shock.  The  autopsy  showed  the  uterus  enlarged  and 
retroverted.  The  right  tube  was  tortuous  and  generally  thickened.  Near 
its  distal  end  it  was  dilated  into  a  swelling  the  size  of  a  hen's  egg,  in  the 
centre  of  which  was  a  cavity  containing  cheesy  material.,  Other  small 
caseous  foci  were  found  in  the  tubal  wall  in  close  proximity  to  the  large 
swelling.  The  ovary  on  the  same  side  was  enlarged  and  transformed  into 
a  caseous  mass.  The  left  tube  and  ovary  showed  similar  changes,  though 
less  extensive.  The  microscopical  examination  of  the  pathological  product 
confirmed  the  diagnosis  of  tuberculosis.  Although  the  disease  appears  to 
have  been  primary  in  the  tubes,  the  affection  occurs  more  frequently  from 
the  direct  extension  of  a  tubercular  endometritis  to  the  tubes.  Lebedeff 
gives  a  full  description  of  a  case  that  came  under  his  observation.  The 
patient  was  the  widow  of  a  man  who  had  died  of  pulmonary  tuberculosis. 
An  examination  before  the  operation  revealed  a  firm,  nodulated,  intraab- 
dominal tumor  in  the  space  of  Douglas.  An  attempt  was  made  to  remove 
the  tumor  by  laparotomy,  but  had  to  be  abandoned,  as  the  disease  had  be- 
come too  widely  disseminated.  Six  weeks  later  the  patient  died  with 
symptoms  of  general  tuberculosis.     At  the  post-mortem  miliary  tubercu- 


TUBEECULOSIS    OF    THE    GENITO-UKINARY    ORGANS.  607 

losis  was  found  in  the  peritoneum,  lungs,  colon,  uterus,  and  Fallopian 
tubes.  The  most  advanced  stages  of  the  disease  were  found  in  the  uterus 
and  Fallopian  tubes,  showing  that  the  disease  had  commenced  in  these 
organs.  Both  of  the  Fallopian  tubes  were  dilated  and  filled  with  pus,  the 
epithelium  in  parts  being  absent.  Stained  sections  from  the  uterus  and 
tubes  showed  the  presence  of  numerous  bacilli.  , 

Symptoms  and  Diagnosis. — Tubercular  salpingitis,  occurring  as  a  sec- 
ondary lesion  to  a  primary  tuberculosis  in  the  lower  portion  of  the  genital 
tract,  can  be  suspected  if,  in  connection  with  a  cervical  or  endometritic 
tuberculosis,  examination  reveal  a  swelling  in  the  region  of  one  or  both 
Fallopian  tubes.  Primary  tubercular  disease  of  the  Fallopian  tubes  gives 
rise  to  local  conditions  and  symptoms  that  it  would  be  impossible  to  differ- 
entiate from  an  ordinary  pyosalpinx.  The  existence  of  a  dilated,  inflamed 
Fallopian  tube  can  generally  be  made  out  with  some  degree  of  certainty 
by  making  the  examination  while  the  patient  is  under  the  influence  of  an 
anesthetic.  Worth  has  described  an  acute  and  chronic  form  of  tubercular 
salpingitis.  In  the  acute  variety  both  the  muscular  and  serous  coats 
undergo  caseous  degeneration,  numerous  bacilli  being  found  in  the  in- 
terior of  the  tube;  while  in  the  chronic  form  the  wall  of  the  tube  under- 
goes thickening  and  infiltration  with  new  cells,  and  its  contents  contain 
only  a  few  bacilli.  The  increase  in  size  of  the  tube  is  due  to  the  collection 
of  pus  in  its  interior  as  well  as  to  the  thickening  of  the  wall.  When  sup- 
puration takes  place  in  the  interior  of  the  tube  the  tubercular  product  has 
become  the  seat  of  a  secondary  infection  with  pus-microbes;  hence  indica- 
tions for  operative  treatment  have  become  more  urgent.  If  the  tuber- 
cular inflammation  extend  from  the  abdominal  extremity  of  the  Fallopian 
tube  to  the  peritoneum,  symptoms  of  tubercular  salpingitis  are  obscured 
later  on  by  those  of  tubercular  peritonitis. 

Treatment. — As  a  tubercular  salpingitis  calls  for  the  same  treatment 
as  a  pyosalpinx,  it  is,  for  all  practical  purposes,  only  necessary  to  narrow 
the  diagnosis  down  to  either  one  of  these  two  affections  before  resorting 
to  treatment  by  laparotomy.  A  median  incision  is  preferable  to  a  lateral, 
as  frequently  both  tubes  are  affected  simultaneously.  Salpingectomy 
should  be  combined  with  oophorectomy,  as  the  ovaries  are  frequently  im- 
plicated in  the  tubercular  process,  and  these  organs  would  be  of  no  further 
use  after  extirpation  of  the  tubes.  As  tubercular  tubes  are  usually  found 
firmly  adherent  to  the  surrounding  tissues,  their  removal  is  often  at- 
tended with  the  greatest  difficulties,  and  may  become  an  impossible  task. 
If  the  disease  is  limited  to  the  tube-structures,  and  has  not  involved  sur- 
rounding important  organs,  it  would  appear  rational,  under  such  circum- 
stances, to  lay  the  tube  open,  remove  its  contents,  scrape  out  the  infected 
tissues  as  far  as  possible,  arrest  bleeding  by  applying  the  actual  cautery. 


608  PKINCIPLES    OF    SUKGEKY. 

and,  after  thorough  iodoformization,  pack  with  iodoform  gauze.  This 
treatment  woukl  certainly  appear  more  rational  than  to  be  content  with 
an  exploratory  incision  and  allow  the  patient  to  remain  a  sufferer  until 
relieved  by  death  from  tuberculosis.  In  one  case  that  came  under  my 
treatment,  where  both  tubes  were  imbedded  in  a  mass  of  granulation- 
tissue,  I  was  unable  to  remove  the  entire  mass,  and  I  was  compelled  to  pursue 
this  course,  and  the  patient  recovered  quickly  and  permanently,  in  spite 
of  a  fgecal  fistula  that  formed  a  few  days  after  the  operation. 

TUBERCULOSIS    OF   THE    OVARY. 

Primary  tuberculosis  of  the  ovary  is  comparatively  rare.  More  fre- 
quently the  organ  becomes  secondarily  involved  by  extension  of  the  dis- 
ease from  the  Fallopian  tube  or  peritoneum.  Orthmann  has  collected  177 
eases.  Only  57  were  submitted  to  a  careful  microscopical  examination, 
and  of  these  48  were  typical  instances  of  ovarian  tuberculosis.  The  dis- 
ease was  bilateral  in  27  cases.  The  remaining  9  were  tubercular  ovarian 
cysts.  Of  the  48  cases,  infection  was  traced  to  the  Fallopian  tube  in  26 
and  from  the  peritoneum  in  22.  In  the  48  cases  the  tubercle  bacillus  was 
found  9  times  by  microscopical  examination  and  4  times  by  inoculation 
experiments. 

TUBERCULOSIS    OF   GLANS   PENIS   AND   URETHRA. 

Kraske  has  observed  a  case  of  tubercular  ulceration  of  the  urethra, 
extending  from  the  membranous  portion  of  the  neck  of  the  bladder,  in 
a  patient,  33  years  of  age,  who  was  treated  for  chancre.  The  autopsy 
revealed  advanced  tuberculosis  of  the  genito-urinary  tract  and  pulmonary 
tuberculosis.  In  another  case,  a  man  49  years  old,  a  tubercular  ulcera- 
tion existed  on  the  dorsum  of  the  glans  the  size  of  a  cent  piece.  This 
sore  was  also  mistaken  for  a  primary  lesion  of  syphilis.  There  were  no 
signs  of  pulmonary  tuberculosis.  The  glans  was  amputated,  when  it  was 
observed  that  the  tubercular  inj&ltration  extended  deeply  into  the  cav- 
ernous structure.  The  lesion  could  not  be  traced  to  genital  contact,  and 
under  the  microscope  showed  the  typical  structure  of  tubercular  tissue. 
In  the  examination  of  doubtful  lesions  of  the  glans  penis  it  is  well  to 
remember  the  possibility  of  tubercular  infection  in  this  locality,  and,  in 
case  the  tubercular  nature  of  a  lesion  can  be  established  on  sufficient 
grounds,  to  resort  to  cauterization  with  the  actual  cautery,  excision,  or 
amputation,  according  to  the  location  and  extent  of  the  disease. 

TUBERCULOSIS   OP  EPIDIDYMIS   AND   TESTICLE. 

In  the  male  genital  apparatus  tuberculosis  attacks  most  frequently 
the  epididymis,  for  the  reason  that  the  vessels  in  this  structure  are  more 


TUBEECULOSIS    OF    EPIDIDYMIS    AND    TESTICLE.  609 

tortuous  and  smaller  than  in  the  remaining  portion  of  the  testicle  or  the 
vas  deferens,  both  of  which  are  important  elements  in  determining  locali- 
zation in  that  part  from  floating  bacilli  that  reach  it  through  the  circu- 
lating blood.  Salzmann  states  that  these  anatomical  conditions  are  im- 
portant factors  in  the  arrest  and  localization  of  floating  bacilli.  That  in 
cases  of  tuberculosis  of  the  testicle  we  are  onl}'  dealing  with  an  external 
manifestation  of  an  antecedent  infection  becomes  apparent  by  the  clinical 
observation  that  not  infrequently  both  testicles  are  infected,  either  simul- 
taneously or  some  time  apart,  showing  that  the  infection  came  from  the 
same  source.  Guyon  ("La  Castration  pour  le  Sarcocele  tuberculeux," 
Ann.  des  Mai.  des  Org.  Gendto-urin.,  1891,  vol.  ix,  No.  7)  believes  that 
tuberculosis  of  the  genito-urinary  organs  occurs  quite  frequently  as  a 
primary  affection.  He  is  of  the  opinion  that  tuberculosis  of  the  epididy- 
mis is  almost  always  complicated  by  a  similar  affection  of  the  prostate  and 
vesiculas  seminales,  and  is  therefore,  on  the  whole,  opposed  to  castration 
as  a  curative  operation.  He  maintains  that  this  operation  is  only  Justi- 
fiable after  the  disease  of  the  epididymis  has  resulted  in  the  formation  of 
abscesses  and  fistulous  openings.  Tuberculosis  of  the  genital  organs  in 
the  male  furnishes  one  of  the  best  examples  of  the  typical  clinical  course 
of  local  tuberculosis.  The  disease  extends,  by  continuity  of  structure, 
often  to  a  great  distance  from  its  starting-point.  Nothing  is  more 
familiar  than  the  clinical  course  of  a  case  of  tuberculosis  of  the  testicle. 
A  small,  hard  nodule  is  first  detected  in  the  epididymis,  and  from  this 
point  the  whole  structure  of  the  epididymis  is  infected,  when  the  infection 
slowly,  but  surely,  extends  to  the  testicle;  then  along  the  vas  deferens 
to  the  vesiculffi  seminales,  the  prostate  gland,  and  bladder,  and  from  this 
viscus  along  the  ureters  to  the  pelvis  of  the  kidney.  As  a  rule,  the  dis- 
ease remains  limited  to  the  genito-urinary  organs,  but  in  some  instances 
metastatic  infection  takes  place,  either  from  the  genito-urinary  organs 
or  from  the  primary  source  of  the  infection.  A  gentleman  was  under  my 
care  whose  case  illustrates  a  number  of  interesting  points  descriptive  of 
the  clinical  behavior  of  genital  tuberculosis.  He  was  35  years  of  age;  mar- 
ried for  ten  years;  the  marriage  had  been  childless.  He  claimed  that  he 
never  had  syphilis  or  gonorrhoea.  Tuberculosis  is  hereditary  in  the  family. 
Nine  years  before  he  noticed  a  small,  hard  swelling  in  the  epididymis  of 
both  testicles.  Two  years  before  symptoms  of  cystitis  appeared,  which 
were  not  much  improved  by  internal  medication  and  antiseptic  irrigation 
of  the  bladder.  Six  months  before  his  left  knee  became  swollen  and 
painful.  Four  months  later  he  commenced  to  sufi:er  severe  pain  in  the 
region  of  the  left  kidney.  Temperature  varied  from  100°  to  103°  F.  A 
swelling  soon  formed  in  the  left  lumbar  region,  and  four  weeks  later  I 
evacuated  a  large  quantity  of  pus  through  a  lumbar  incision.     Through 


610  PKINCIPLES    OF    SURGEEY. 

the  incision  the  kidney  could  be  seen  and  felt,  and,  by  passing  the  index 
finger  around  it,  it  appeared  to  be  extensively  separated  from  the  con- 
tiguous structures.  The  left  knee  presented  all  the  appearances  of  ad- 
vanced synovial  tuberculosis.  No  evidences  of  pulmonary  tuberculosis. 
The  disease  in  both  testicles  had  made  no  progress  for  years,  and  the 
infiltration  appears  to  be  limited  to  the  epididymis.  The  epididymis  on 
both  sides  is  moderately  swollen  and  indurated.  The  vas  deferens  on 
each  side  is  somewhat  larger  and  firmer  than  normal.  The  disease  had 
extended  from  the  epididymis  to  the  pelvis  of  the  kidney  on  both  sides, 
all  of  the  intervening  organs  being  involved  in  the  tubercular  process. 
The  only  apparent  manifestation  of  general  tuberculosis  was  presented 
by  the  left  knee.  An  interesting  feature  in  this  case  was  the  formation  of 
a  paranephritic  abscess  around  a  pyelonephritic  kidney,  which  must  be 
regarded  as  the  result  of  a  secondary  infection  with  pus-microbes. 

Symptoms  and  Diagnosis. — Tubercular  epididymitis  always  appears 
as  a  chronic  affection,  in  this  respect  differing  from  gonorrhoeal  epididy- 
mitis and  the  ordinary  form  of  acute  parenchymatous  and  suppurative 
orchitis.  Pain  and  tenderness  are  either  entirely  absent  or,  at  least, 
slight  when  present.  Circumscribed  hydrocele  may  develop  as  soon  as 
the  disease  extends  to  the  tunica  vaginalis.  The  tubercular  inflamma- 
tion is  characterized  by  the  same  pathological  conditions  as  in  other 
organs,  new  nodules  appearing  in  the  neighborhood  of  the  first  one,  which, 
by  confluence,  form  masses  of  considerable  size.  Caseation  is  an  early 
and  almost  constant  condition.  In  many  cases  the  process  extends  in  the 
direction  of  the  skin;  a  tubercular  abscess  forms  in  the  tunics  of  the 
scrotum;  the  skin  presents  a  bluish-red  color,  and  spontaneous  perfora- 
tion gives  rise  to  evacuation  of  the  abscess.  Frequently  multiple  abscesses 
form  in  this  manner,  and  the  fistulous  openings  lead  down  to  caseous 
masses.  In  some  cases,  as  the  one  reported,  the  disease  in  the  epididymis 
becomes  latent,  but  the  infection  extends  at  an  early  date  along  the  vas 
deferens,  which  becomes  swollen,  hard,  and  nodular,  and  from  Avhich,  if 
a  cross-section  is  made,  the  characteristic  cheesy  material  can  be  squeezed. 
From  the  vas  deferens  the  disease  extends  to  the  vesiculae  seminales,  pros- 
tate gland,  bladder,  and  finally  creeps  along  the  ureters  to  the  pelvis  of 
the  kidney,  usually  simultaneously  on  both  sides.  The  only  disease  with 
which  tubercular  epididymitis  might  be  confounded  is  tertiary  syphilis 
affecting  the  same  part  of  the  testicle.  In  cases  of  doubt  the  patient 
should  be  placed  on  antisyphilitic  treatment  for  a  few  weeks,  which,  if 
the  affection  is  tubercular,  will  produce  no  impression  on  the  swelling;  on 
the  other  hand,  if  it  is  syphilitic,  it  will  rapidly  diminish  in  size. 

Treatment. — The  only  radical  treatment  in  tuberculosis  of  the  epi- 
didymis and  testicle  is  castration.     This  operation  is  indicated  if  the  dis- 


TUBEECULOSIS    OF    THE    VESICUL^    SEMINALES.  611 

ease  is  limited  to  one  testicle^  and  no  evidences  of  tuberculosis  can  be 
found  in  any  other  organ  beyond  the  reach  of  surgical  treatment.  I  have 
removed  both  testicles  in  two  cases,  but  in  both  patients  tubercular  cys- 
titis developed  one  and  two  years,  respectively,  after  the  operation,  and 
in  one  of  them  the  immediate  cause  of  death  was  pulmonary  tuberculosis. 
My  own  cases  and  the  experience  of  other  surgeons  would  tend  to  dictate 
a  conservative  course  of  treatment  if  both  testicles  are  affected.  In  per- 
forming castration  for  malignant  or  tubercular  affections  of  the  testicle 
the  surgeon  should  aim  to  remove  as  much  of  the  spermatic  cord  as 
possible.  The  inguinal  canal  should  be  laid  open  freely  and,  by  patient 
traction  on  the  cord,  as  much  as  possible  of  this  structure  beyond  the 
internal  inguinal  ring  should  be  secured  and  removed.  After  the  disease 
has  extended  to  the  organs  at  the  base  of  the  bladder  or  the  bladder  itself, 
castration  is,  of  course,  positively  contraindicated.  Eeboul,  of  Marseilles, 
treated  three  cases  of  this  disease  by  injections  of  naphthol-camphor.  He 
injected  4  to  5  drops  every  eight  to  ten  days  into  the  thickened  tissues  of 
testicle  and  epididymis.  Marked  improvement  was  effected,  the  diseased 
parts  becoming  more  indurated  and  contracted;  and  these  results  are  the 
more  noteworthy  since  in  two  of  the  cases  other  measures  continued  for 
a  long  time  had  been  unsuccessful.  The  coexistence  of  pulmonary  tuber- 
culosis, or  tuberculosis  of  any  of  the  larger  joints,  would  furnish  a  suffi- 
cient ground  against  the  propriety  of  castration.  Castration  is  a  legiti- 
mate operation,  and  yields  fair  results  if  the  patient  is  otherwise  in  good 
health  and  the  disease  is  limited  to  one  side,  and  has  not  extended  along 
the  cord  beyond  a  point  where  all  of  the  infected  tissues  can  be  removed. 
The  tunica  vaginalis  should  always  be  removed  with  the  testicle,  and,  if 
the  scrotum  is  adherent  at  any  point,  the  adherent  portions  of  the  skin 
must  be  excised  at  the  same  time.  The  vessels  of  the  cord  should  be 
tied  separately,  as  tying  the  cord  en  masse  gives  rise  to  unnecessary  pain, 
and  the  ligature  is  liable  to  slip:  an  occurrence  that  might  be  followed  by 
troublesome  haemorrhage.  If  the  disease  is.  bilateral  and  has  resulted  in 
abscess  formation  much  can  be  gained  by  the  vigorous  use  of  the  sharp 
spoon  followed  by  the  local  use  of  iodoform.  Recently  much  has  been 
said  in  favor  of  resection  of  the  tubercular  epididymis  as  a  substitute 
for  castration,  but  it  is  very  doubtful  if  the  claims  advanced  will  be  sup- 
ported by  clinical  experience. 

TUBEECULOSIS    OF    THE    VESICUL^    SEMINALES. 

In  1829  Dahmar  described  a  chronic  inflammation  of  the  seminal 
vesicles,  the  description  of  which  corresponds  closely  to  that  of  tuber- 
culosis. Since  then  this  affection  has  been  described  by  Albers,  Jaye, 
Naumann,  Humphrey,   and  Kocher,   and  lately  it  has  been  studied  by 


612  PRINCIPLES    OF    SURGERY. 

Eayer,  Cruveilhier,  and  Eeclus  as  secondary  to  pulmonary  tuberculosis. 
As  a  secondary  affection  this  ailment  is  not  only  seen  in  connection  with 
tuberculosis  of  the  lungs,  but  is  more  common  after  primary  tubercu- 
losis of  the  epididymis,  either  as  a  continuation  of  the  cheesy  degenera- 
tion in  the  vas  deferens  or  spreading  by  contiguity  of  tissue  from  the 
sides  of  the  prostate.  Primary  tuberculosis  of  these  organs  is  extremely 
rare,  and  still  less  often  diagnosed,  and  up  to  quite  recently  no  surgical 
interference  has  been  attempted.  Ullmann  now  reports  a  case  of  primary 
tuberculosis  of  the  right  testicle,  with  secondary  affection  of  the  seminal 
vesicles  on  both  sides^  in  a  lad  17  years  of  age,  where,  after  removal  of 
the  right  testicle,  he  extirpated  these  organs  through  a  semilunar  incision 
in  the  perineum.  The  general  health  of  the  patient  improved  after  the 
operation,  but  a  small  urinary  fistula  remained,  which  formed  in  conse- 
quence of  injury  to  the  base  of  the  bladder  during  the  operation.  He  is 
of  the  opinion  that  the  seminal  vesicles  should  be  removed  in  primary 
tuberculosis  of  the  testicle  or  epididymis,  when  no  suspicious  symp- 
toms have  appeared  on  the  sound  side,  and  when  on  the  affected  side 
the  vesiculse  seminales  are  already  attacked;  also  in  cases  of  primary 
tuberculosis  of  the  seminal  vesicles.  Fenger  has  also  reported  a  successful 
extirpation  of  the  vesiculge  seminalis  for  tuberculosis.  More  recently  Boux, 
of  Paris,  has  advanced  the  idea  that  in  tuberculosis  of  the  genital  organs  it  is' 
a  mistake  to  remove  only  the  testicles,  since,  he  has  often  observed  fistulas  and 
abscesses  extending  along  the  cord  after  castration.  He  advises,  in  addi- 
tion, extirpation  of  the  vas  deferens  and  seminal  vesicles.  He  reports 
two  cases  in  which,  after  removal  of  the  testicle,  the  vas  deferens  was 
carefully  separated  from  the  vessels  of  the  spermatic  cord,  which  were 
then  tied  and  divided.  An  incision  was  then  made  in  the  perineum,  the 
vesiculse  seminales  pushed  into  the  wound  by  the  finger  introduced  into 
the  rectum  and  excised,  and  the  vas  deferens  entirely  removed.  The  re- 
sults were  excellent.  The  impotence  following  the  operation  should  be 
no  contraindication,  for  in  all  reported  cases  of  tuberculosis  of  the  seminal 
vesicles  imjDotence  always  occurs  in  a  short  time;  in  fact,  it  is  regarded  as 
a  cardinal  S3aiiptom  of  the  disease. 

TUBERCULOSIS  OF  THE  BLADDER. 

Tuberculosis  of  the  bladder  occurs  either  as  a  primary  or  secondary  af- 
fection. Several  cases  of  well-marked  primary  tuberculosis  of  the  bladder  in 
the  female  have  come  under  my  observation,  where  the  disease  evidently 
commenced  at  the  neck  of  the  bladder,  and,  after  spreading  over  the  whole 
internal  surface  of  the  viscus,  extended  along  the- ureters  to  the  pelves 
of  the  kidneys,  and  finally,  in  the  course  of  a  few  years,  proved  fatal  from 
tubercular  pyelonephritis.    Primary  tubercular  cystitis  appears  to  be  more 


TUBEECULOSIS  OF  THE  BLADDEK.  613 

frequent  in  females  than  in  males,  undoubtedly  because,  on  account  of 
shortness  of  the  urethra,  direct  infection  is  more  liable  to  occur. 

Striimpell,  after  a  careful  study  of  4  cases  of  primary  tuberculosis 
of  the  bladder  in  men,  came  to  the  conclusion  that  infection  takes  place 
through  the  urethra.  The  tubercle  bacilli,  finding  no  favorable  place  for 
localization  and  growth  in  the  urethra  and  bladder,  finally  reach  the 
prostate  gland  or  the  epididymis,  the  whole  process  resembling  what 
occurs  in  inhalation  tuberculosis,  in  which  the  disease  manifests  itself 
not  in  the  mucous  membrane  of  the  bronchial  tubes,  but  in  the  paren- 
chyma of  the  apices  of  the  lungs. 

More  frequently,  however,  tubercular  cystitis  follows  a  descending 
tubercular  ureteritis  or  in  consequence  of  an  extension  of  a  tubercular 
process  from  the  epididymis  along  the  spermatic  cord  to  the  vesiculge  semi- 
nales,  prostate  gland,  and  base  of  the  bladder.  If  the  disease  reach  the 
bladder  from  above,  the  mucous  membrane  around  the  ureteral  orifice  is 


W^ 


Fig.  200.— Tubercle  Bacilli  in  Urine. 


first  involved,  and  from  here  the  disease  spreads  over  the  mucous  surface 
of  the  organ.  On  the  other  hand,  infection  from  below  is  first  manifested 
by  symptoms  which  indicate  irritation  and  inflammation  of  the  neck  of  the 
bladder. 

Symptoms  and  Diagnosis. — Tuberculosis  of  the  bladder  is  clinically 
characterized  by  symptoms  of  cystitis,  the  intensity  of  the  symptoms 
varying  according  to  the  part  of  the  bladder  affected,  the  extent  of  the 
disease,  and  the  presence  or  absence  of  complications.  If  the  disease 
primarily  involve  the  neck  of  the  bladder,  tenesmus  and  frequent  desire 
to  urinate  are  the  most  distressing  symptoms.  As  long  as  no  ulceration 
of  the  vesical  mucous  membrane  has  taken  place,  the  urine  may  present 
a  perfectly  normal  appearance,  and,  on  examination,  is  found  normal  in 
other  respects.  Slight  attacks  of  hematuria  are  of  frequent  occurrence. 
Very  frequently  the  symptoms  become  very  much  aggravated  shortly  after 
an  examination  of  the  bladder,  made  upon  the  supposition  that  the  patient 
is  sufi^ering  from  stone  in  the  bladder,  as  the  introduction  of  a  sound 


614  PEINCIPLES    OF    SUEGEEY. 

without  the  necessary  aseptic  jDrecautions  is  often  followed  by  a  sec- 
ondary infection  with  pus-microbes,  w^hich  gives  rise  to  an  acute  sup- 
purative cystitis.  The  general  health  of  the  patient  now  becomes  rapidly 
undermined,  and  the  extension  of  the  local  disease  in  the  direction  of 
the  kidneys  is  hastened.  The  urine  contains  large  quantities  of  pus  and 
mucus,  and  becomes  ammoniacal  from  the  presence  and  action  of  putre- 
factive bacteria.  The  walls  of  the  bladder  become  greatly  thickened  from 
inflammatory  exudation  and  tubercular  infiltration;  the  organ  is  unable 
to  empty  itself  completely,  and  the  decomposed  residual  urine  becomes 
an  additional  source  of  irritation  and  progressive  infection.  Incontinence 
of  urine  is  a  frequent  symptom  in  advanced  vesical  tuberculosis,  and  is 
usually  an  indication  that  the  organ  is  extensively  diseased.  In  secondary 
tuberculosis  of  the  bladder  it  is  usually  not  difficult  to  locate  the  primary 
disease,  and  thus  establish  a  positive  diagnosis.  The  presence  of  tubercle 
bacilli  in  the  urine  in  cases  of  primary  tuberculosis  of  the  organ  fur- 
nishes a  positive  diagnostic  criterion  between  ordinary  cystitis  and 
vesical  tuberculosis.    In  the  absence  of  the  ordinary  causes  of  cystitis,  such 


V^}'W.-/ -A^i  ■]     ■■■A  \  v_/ .  -^  -  • 


Fig.  201. — Tubercle  Bacilli  in  Urine.    (Cornil  and  Bahes.) 

as  gonorrhoea,  stricture  of  the  urethra,  enlarged  prostate,  calculus,  and 
tumors  of  the  bladder,  symptoms  of  cystitis  point  strongly  toward  a 
tubercular  origin  of  the  inflammation,  and  should  induce  the  surgeon  to 
make  a  most  careful  examination  in  reference  to  the  etiology  and  nature 
of  the  cystitis.  It  is  only  by  excluding  the  presence  of  the  different  lesions 
of  the  bladder  by  a  careful  and  thorough  examination  of  that  viscus  and  its 
neighboring  organs,  as  well  as  a  chemical,  microscopical,  and  bacterio- 
logical examination  of  the  urine,  that  a  positive  diagnosis  of  vesical 
'tuberculosis  can  be  made  during  the  early  stages  of  the  disease.  In  tuber- 
culosis of  the  pelvis  of  the  kidney  or  bladder  free  bacilli  can  often  be  found, 
and  sometimes  their  presence  can  be  detected  in  the  cells.  Tubercular 
urine  injected  into  the  peritoneal  cavity  of  a  guinea-pig  will  produce 
tuberculosis  in  this  animal,  and  in  doubtful  cases  this  diagnostic  measure 
may  prove  of  great  value. 

Prognosis  and  Treatment. — In  secondary  tuberculosis  of  the  bladder 
the  regional  infection  has  extended  so  far  that  even  the  most  heroic 
surgical  measures  will  necessarily  fail  in   eliminating  the   disease,   and 


TUBERCULOSIS    OF    THE   BLADDER.  615 

death  from  extension  of  the  infection  to  the  kidneys,  or  from  secondary 
pulmonary  or  general  tuberculosis,  will  follow  as  an  inevitable  result.  In 
primary  vesical  tuberculosis  the  disease,  at  the  time  a  positive  diagnosis 
can  be  made,  has  usually  invaded  so  much  of  the  walls  of  the  bladder 
that  a  radical  operation  would  necessitate  an  extensive  resection  of  its 
walls,  after  which  it  would  be  found  impossible  to  utilize  the  remaining 
.portion  of  the  organ  as  a  reservoir  for  the  urine.  Kesection  of  the  wall 
of  the  bladder  has  been  done  in  several  instances  in  the  treatment  of 
malignant  tumors  at  its  base,  but  has  usually  terminated  in  the  formation 
of  a  permanent  urinary  fistula. 

Dr.  E.  Harvey  Eeed,  of  Mansfield,  Ohio,  made  an  interesting  series  of 
experiments  on  dogs,  with  a  view  to  dispense  with  the  bladder  altogether  in 
cases  of  extensive  disease  of  this  organ,  necessitating  partial  or  complete  ex- 
cision. He  has  shown  that  the  ureters  can  be  successfully  implanted  into  the 
rectum,  thus  excluding  permanently  the  urinary  tract  below  this  point  from 
the  urinary  passages,  and  utilizing  the  rectum  as  a  reservoir  for  the  urine.  If 
the  operation  of  implantation  of  the  ureters  into  the  rectum  can  be  perfected 
to  such  an  extent  as  to  become  a  feasible  and  practical  procedure  in  surgery 
it  may  be  possible,  in  the  future,  that  vesical  tuberculosis  can  be  successfully 
dealt  with  by  complete  excision  of  the  affected  organ.  Implantation  of  both 
ureters  into  the  sigmoid  flexure  has  been  successfully  performed  by  Dr.  C. 
Beck,  of  Chicago,  and  others  for  vesical  tuberculosis,  and  this  operation  or  a 
modification  of  it  recommends  itself  in  cases  in  which  the  tubercular  affec- 
tion is  limited  to  the  bladder.  It  appears  to  me  the  implantation  of  the 
right  ureter  into  a  healthy  appendix  vermiformis  and  implantation  of  the 
left  into  the  sigmoid  fiexure  would  be  a  feasible  operation,  and,  if  per- 
formed in  two  stages,  would  greatly  reduce  the  immediate  sources  of 
danger. 

The  conservative  treatment  of  vesical  tuberculosis  by  injection  of 
solutions  of  boric  acid,  benzoate  of  soda,  the  ordinary  antiseptic  solu- 
tions, and  iodoform  has  little  or  no  effect,  either  in  affording  palliation  or 
in  retarding  the  regional  extension  of  the  disease.  Guyon  recommends 
corrosive  sublimate  as  an  excellent  remedy  in  cystitis,  but  especially  in 
vesical  tuberculosis.  The  remedy  is  employed  either  in  the  form  of  irri- 
gation or  instillation,  the  latter  being  preferred  by  the  author.  The 
strength  of  the  sublimate  solutions  varied  from  1-5000  to  1-1000.  At 
the  beginning  of  treatment  20  to  30  drops  are  injected  into  the  posterior 
urethra,  and  this  quantity  is  gradually  increased  to  60  drops.  The  more 
severe  the  pain,  the  less  should  be  the  quantity  injected.  Before  the 
instillations  the  bladder  must  be  emptied.  The  remedy  that  has  yielded 
better  results  in  my  hands  than  any  other  in  the  local  treatment  of  vesical 
tuberculosis  is  trichloride  of  iodine.     The  treatment  must  be  commenced 


616  -  PEINCIPLES    OF    SUEGEEY. 

with  a  very  weak  solution^ — V4  per  cent.,  the  strength  gradually  in- 
creased to  1  per  cent,  as  the  bladder  becomes  more  tolerant  to  the  action 
of  this  drug.  The  bladder  should  first  be  washed  out  with  sterilized  water 
and  not  more  than  an  ounce  of  the  solution  injected  at  a  time.  Eeniae 
reports  cases  of  tubercular  cystitis  treated  by  instillation  of  1  ounce  of 
liquid  vaselin  containing  25  grains  of  iodoform.  The  oily  material  floats 
upon  the  urine.  When  the  patient  micturates  the  urine  at  first  escapes 
free  from  oil,  but  toward  the  end  of  the  act  it  appears,  and  as  soon  as  this 
is  the  case  further  escape  ceases.  In  this  manner  the  iodoform  is  detained 
in  the  bladder  many  days.  When  it  disappears  a  new  instillation  is  made. 
Iodoform  thus  used  relieves  pain  and  promotes  the  healing  of  the  ulcera- 
tions. He  gives  the  particulars  of  14  cases  treated  by  this  method,  of 
which  number  7  were  greatly  improved,  6  considerably  benefited,  1  not  im- 
proved. Internal  medicines — such  as  boric  acid,  benzoate  of  soda,  uva  ursi, 
buchu,  triticum  repens,  and  urotropin — are  of  utility  in  relieving  vesical 
tenesmus,  before  secondary  infection  with  pus-microbes  and  putrefactive  bac- 
teria has  occurred,  by  rendering  the  urine  alkaline  and  more  copious; 
but  during  the  later  stages  of  the  disease  they  are  useless  even  as  palli- 
atives. If  the  tubercular  process  is  limited  to  the  urinary  passages  below 
the  ureters,  incision  and  drainage  of  the  bladder  secure  rest  to  this  organ 
and  open  up  a  direct  route  for  the  more  effectual  treatment  of  the  tuber- 
cular lesions,  and  thus  not  only  constitute  the  most  efficient  palliative 
measure,  but  also  the  most  effective  procedure  in  retarding  the  local  ex- 
tension of  the  disease  by  direct,  vigorous,  antitubercular  treatment.  I 
had  an  opportunity  to  observe  the  palliative  effect  of  an  opening  in  the 
bladder,  in  a  case  of  primary  vesical  tuberculosis  in  a  female  aged  35  years, 
where  the  tubercular  ulceration  resulted  in  the  formation  of  a  vesico- 
vaginal fistula.  The  tenesmus  was  promptly  relieved,  as  soon  as  the 
bladder  was  placed  in  a  condition  of  rest,  by  the  escape  of  urine  through 
the  fistulous  opening. 

In  the  female  the  most  direct  route  into  the  bladder,  and  affording 
the  most  efficient  drainage  and  furnishing  the  most  advantageous  condi- 
tions for  the  local  treatment  of  the  tubercular  lesions,  is  a  vaginal  cys- 
totomy made  near  the  neck  of  the  bladder.  The  opening  should  be  at 
least  1  ^/o  inches  in  length,  extending  from  near  the  neck  of  the  bladder 
in  an  upward  direction.  Tubular  drainage  should  be  dispensed  with,  as 
all  foreign  substances  in  the  bladder  not  only  act  as  irritants,  but  inter- 
fere with  complete  drainage.  As  the  opening  is  made  in  the  most  de- 
pendent portion  of  the  bladder,  free  drainage  can  be  secured  most  effi- 
ciently by  means  which  prevent  contraction  or  closure  of  the  vesico- 
vaginal opening.  This  can  be  done  by  suturing  the  mucous  membrane  of 
the  bladder  to  the  vaginal  mucous  membrane,  thus  establishing  a  perma- 


TUBEKCULOSIS    OF    THE   KIDNEY.  •  617 

nent  bimucous  fistula  iDetween  the  bladder  and  the  vagina.  Through  this 
opening  accessible  tubercular  lesions  can  be  treated  by  the  use  of  the 
sharp  spoon  and  the  direct  application  of  iodoform.  The  parts  below  this 
opening  should  be  protected  against  the  irritating  effect  of  urine  by 
applications  of  vaselin  or  lanolin  containing  one  of  the  milder  antiseptic 
remedies.  After  the  fistulous  opening  has  been  established  the  bladder  can 
be  irrigated  with  antiseptic  solutions,  or  a  mixture  containing  iodoform, 
through  the  urethra. 

In  the  male  the  same  objects  are  attained  more  efficiently  by  making 
a  suprapubic  cystotomy,  as  through  a  perineal  incision  the  direct  treat- 
ment of  tubercular  lesions  is  impossible.  The  fistulous  communication 
should  be  made  complete  by  suturing  the  margins  of  the  visceral  wound 
to  skin-flaps  taken  from  each  side  of  the  external  incision:  a  method  first 
suggested  by  Morris,  of  New  York.  By  lining  the  margins  of  the  incision 
with  mucous  membrane  and  skin,  the  loose  connective  tissue  in  the  pre- 
vesical space  is  protected  against  infection,  and  the  fistulous  opening  is 
rendered  permanently  patent.  At  the  time  of  operation  visible  tubercular 
ulcers  are  curetted  and  iodoformized.  The  bladder  can  be  irrigated  sub- 
sequently through  the  urethra  or  through  the  fistulous  opening. 

In  a  case  of  advanced  primary  tuberculosis  of  the  bladder  where  I 
pursued  this  method  of  treatment  the  operation  afforded  marked  relief, 
but  appeared  to  have  no  influence  in  retarding  a  fatal  termination,  as  the 
disease  had  already  extended  to  the  kidneys.  The  patient  lived  for  nearly 
two  months  in  comparative  comfort,  the  principal  complaint  made  being 
the  moisture  caused  by  the  constant  escape  of  urine  through  the  artificial 
urethra. 

A  case  is  described  by  Battle  in  which  recovery  followed  curetting 
through  a  suprapubic  incision,  after  the  failure  of  less  formidable  means. 
The  patient  was  a  girl  aged  20  years.  The  operation  was  performed  July 
29,  1889.  The  patient  was  discharged  September  20th,  and  April  8,  1890, 
was  in  good  health  and  working  at  her  trade. 

In  cases  where  the  disease  in  the  bladder  is  circumscribed,  and  the 
organ  is  opened  early,  the  treatment  might,  occasionally  at  least,  result 
in  a  permanent  cure,  if  the  infected  tissues  can  be  completely  removed 
by  curetting  or  destroyed  by  the  actual  cautery  through  the  incision  at 
the  time  of  operation.  In  such  favorable  cases  the  opening  should  not 
be  allowed  to  close  until  the  surgeon  can  satisfy  himself  that  the  ulcers 
have  completely  healed,  and  that  no  new  centres  of  infection  are  present. 

TUBEKCULOSIS   OF  THE   KIDNEY. 

The  frequency  with  which  the  kidneys  are  affected  by  primary 
tuberculosis  remains  a  much  disputed  question.     James  Israel  is  of  the 


618  PEINCIPLES    OF    SURGERY. 

opinion  that  primary  tuloerculosis  of  the  kidney  is  much  more  frequent 
than  secondary,  while  other  equally  competent  authorities  entertain  an 
opposite  view.  The  fact,  however,  remains  that  primary  renal  tubercu- 
losis is  much  more  prevalent  than  was  formerly  supposed.  The  disease 
may  have  its  starting-point  either  in  the  substance  of  the  kidney  or  in  the 
pelvis.  It  is  characterized  clinically  by  pain  and  tenderness  in  the  lumbar 
region  and  along  the  course  of  the  ureter,  liEematuria,  tubercular  tissue 
in  the  urine,  and  at  an  early  stage  by  vesical  irritation.  If  the  ureter 
becomes  obstructed  tubercular  pyonephrosis  follows.  It  is  not  always  easy 
to  differentiate  between  vesical  and  renal  tuberculosis  and  tubercular 
pyelonephritis  and  stone  in  the  kidney.  The  microscope  is  a  valuable 
diagnostic  resource  in  such  cases.  Tuberculosis  of  one  kidney  may  eventu- 
ally involve  the  o]3posite  organ  by  extension  of  the  disease  along  the 
ureter  to  the  bladder  and  from  the  bladder  to  the  opposite  kidney  by  an 
ascending  ureteritis.  In  cases  in  which  the  disease  is  limited  to  one  kid- 
ney an  early  nephrectomy  is  the  proper  treatment.  If  the  opposite  kid- 
ney or  the  bladder,  or  both,  are  involved  a  nephrotomy  is  indicated,  fol- 
lowed by  injections  into  the  pelvis  of  the  kidney  of  antibacillary  remedies, 
such  as  the  trichloride  of  iodine  or  iodoform. 

TUBERCULOSIS    OF   THE   VASCULAR   SYSTEM. 

Mention  has  already  been  made  of  tuberculosis  of  the  heart-muscle. 
It  is  well  known  that  tuberculosis  caused  by  tubercular  emboli  or  localiza- 
tion of  tubercle  bacilli  from  the  circulating  blood  begins  as  an  intra- 
vascular lesion.  In  a  classical  inonograph  on  tubercular  meningitis 
Hektoen  gave  an  accurate  descrij)tion  of  the  histogenesis  of  the  endo- 
vascular  tubercle.  Few  observations  of  tubercular  lesions  within  the  large 
blood-vessels  and  heart  have  been  recorded.  Leyden  found  tubercle 
bacilli  in  the  vegetations  of  4  cases  of  recent  verrucous  endocarditis;  the 
bacilli  were  found  chiefly  in  the  cells.  Hanot  and  Levi  report  a  case  in 
which  tubercle  of  recent  origin  was  found  projecting  upon  the  intima  of 
the  aorta  at  a  point  between  the  origin  of  two  intercostal  arteries.  The 
patient,  a  man  61  years  old,  died  of  jDulmonary  tuberculosis. 


CHAPTEE  XXIV. 

ACTIXOMYCOSIS    HOMINIS. 

Actinomycosis  is  a  form  of  chronic  inflamination  caused  by  the 
presence  of  actinomyces,  or  ray-fungus.  Until  quite  recently  this  disease 
was  included  among  the  malignant  tumors,  and  we  have  reason  to  be- 
lieve that,  in  many  of  the  reported  cases  after  operations  for  sarcoma,  the 
disease  for  which  the  operations  were  done  was  not  sarcoma,  but  actino- 
mycosis. Before  degeneration  of  the  inflammatory  product  has  taken 
place  actinomycosis  resembles  a  tumor  more  closely  than  any  other  in- 
flammatory swelling.  The  swelling  is  composed  largely  of  granulation- 
tissue,  which,  on  examination  under  the  microscope,  presents  an  histo- 
logical structure  that,  in  the  absence  of  other  evidences,  it  would  be  diffi- 
cult or  impossible  to  differentiate  from  a  round-celled  sarcoma.  The  pres- 
ence of  the  specific  fungus  in  the  granulation-tissue  settles  the  diagnosis. 

HISTOEY   OF    THE   DISEASE. 

The  disease,  as  occurring  in  cattle,  was  first  described  by  Bollinger, 
in  1877,  as  a  condition  in  which  sarcoma-like  tumors  were  met  with, 
associated  with  a  peculiar  growth  which,  from  its  structure,  was  named 
"Strahlenpilz"  (ray-fungus),  or  actinomyces.  James  Israel  was  the  first 
to  recognize  the  disease  in  man,  but  it  was  not  generally  understood  until 
the  appearance  of  the  classical  work  of  Ponfick  ("Die  Aktinomykose 
des  Menschen,"  Berlin)  in  1882.  Numerous  articles  on  this  subject  have 
since  appeared  in  the  current  medical  literature;  so  that  Partsch,  in 
1888,  mentioned  in  his  monograph  seventy-five  references,  with  a  supple- 
mental list  of  thirty-three  names  furnished  by  Schuchardt.  Since  the 
publication  of  IsraeFs  case  nu.merous  cases  have  been  reported  by  differ- 
ent observers,  representing  Germany,  England,  Belgium,  Switzerland, 
Eussia,  Austria,  France,  and  America;  so  that  Partsch  in  his  ]3aper  esti- 
mates the  whole  number  up  to  that  time  at  not  less  than  one  hundred, 
and  the  number  of  cases  during  the  last  twelve  years  has  reached  several 
hundred.  While  most  of  the  articles  in  medical  journals  contain  only  a 
description  of  isolated  cases,  it  appears  to  have  been  the  good  fortune  of 
some  of  the  writers  on  this  subject  to  meet  with  a  number  of  cases  in  a 
comparatively  short  time.  Thus,  Hochenegg  reports  7  cases  that  came 
under  his  observation,  and  Moosbrugger  has  increased  the  list  of  pub- 
lished cases  by  10  well-authenticated  and  carefully-recorded  cases.  Eotter 
observed  13  cases  in  two  years.     Albert  has  seen  not  less  than  38  cases 

(619) 


620 


PEINCIPLES    OF    SUEGERY. 


of  actinomycosis  in  man  within  the  past  few  years;  of  these,  8  have  come 
nncler  his  observation  during  two  years.  These  cases  have  come  mostly 
from  Vienna  and  its  vicinity. 

DESCEIPTION"    OF   FUNGUS. 

The  ray-fungus  is  represented  by  a  large  family,  many  members  of 
which  are  not  pathogenic;  many  of  them  are  sajDrophytic.  The  remarks 
here  will  be  limited  to  the  pathogenic  variety,  and  more  especially  to  the 
typical  actinomycosis.  Hektoen  has  contributed  a  very  valuable  paper  to 
the  flora  of  the  ray-fungus  and  the  histology  of  the  actinomycotic  process. 


Fig.  202. — Ray-fungus,  with  One  of  the  Rays  More  Projecting  and  Branching.     {Ponflck.) 

The  actinomycetes  are  widely  distributed  fungi.  They  have  been  isolated 
from  the  air,  water,  soil,  and  from  vegetable  matter,  especially  parts  of 
grain,  such  as  the  chaff  of  rye,  wheat,  barley,  and  oats.  Actinomycelial 
masses  have  been  found  in  various  parts  of  the  body,  under  normal  con- 
ditions, both  in  man  and  animals.  Veterinary  surgeons  have  discovered 
them  in  the  tonsillar  crypts  of  the  hog,  usually  attached  to  fragments  of 
cereals.  Hektoen  found  such  masses  4  times  in  a  series  of  100  tonsils 
examined  in  the  laboratory  of  Eush  Medical  College. 

The  ray-fungus,  or  actinomyces,  is  not,  strictly  speaking,  a  microbe^ 
as  it  is  large  enough  to  be  seen  with  the  naked  eye;  but  its  identity  .can 
only  be  ascertained  from  its  characteristic  structure,  which  requires  the 


DESCEIPTION    OF    FUNGUS. 


621 


use  of  the  microscope.  Bollinger  described  as  peculiar  to  this  disease 
certain  yellow  bodies^  visible  to  the  naked  eye^  always  found  in  the  pus 
of  actinomycotic  abscesses  and  in  the  granulation-tissue  before  suppura- 
tion had  occurred.  Microscopically,  they  were  found  to  consist  of  threads 
similar  to  the  ordinary  mycelium,  which  terminated  in  bulbous  ends. 

The  threads  radiate  from  the  centre,  and  their  clubbed  extremities 
impart  to  the  fungus  the  characteristic  ray-like  appearance.  Sometimes 
but  one  of  these  bulbs  is  connected  with  a  thread;    at  other  times  there 


Fig.  203. — Actinomycelial  Granules  in  Crypt  of  Normal  Human  Tonsil.     X  125.     (Hektoen.) 


may  be  several.  In  some  specimens  one  of  the  rays  projects  far  beyond 
the  others  and  terminates  by  several  bulbous  ends,  as  is  shown  in  Fig.  302. 

A  typical  ray-fungus  develops  from  small,  round  spores,  or  conidia, 
into  solid  cylindrical  threads  which  branch  and  form  a  net-work,  each 
single  thread  with  its  branches  representing  a  single  organism.  From 
the  surface  of  the  mycelial  layer  spring  hyphge,  or  air-threads,  which 
by  segmentation  give  origin  to  short  chains  of  spores  which  secure  the 
propagation  of  the  plant. 

The  majority  of  the  ray-fungi  are  aerobic  and  facultatively  anaerobic. 
Berestneff  properly  divides  the  fungi  of  typical  actinomycosis  into  two 


622 


PEIXCIPLES    OF    SUEGEET. 


large  groups^  tlie  first  forming  long  branching  threads  ■«*ith  a  radiating 
appearance  on  culture-media,  the  second  being  the  polymorphous  micro- 
phytes of  "Wolff  and  Israel  and  others,  the  younger  colonies  of  which  are 
largely  composed  of  cocci-like  and  rod-shaped  masses,  branching  threads 
being  formed  onl}"  on  special  media  or  in  old  cultures. 

In  man  the  actinomyces  occurs  as  a  small,  globular  mass,  commonly 
about  the  size  of  a  millet-seed,  usually  of  a  pale-yellow  color,  but  at  times 
white,  brown,  green,  or  speckled,  the  color  being  influenced  by  age  and 
the  consecutive  pathological  conditions  by  which  it  may  be  surrounded. 
In  man  the  clubbed  bodies  are  often  absent,  and  the  growth  then  consists 
of  the  radiating  filaments  alone.  The  rays,  when  immersed  in  water  or 
in  a  weak  solution  of  chloride  of  sodium,  become  enormously  swollen  and 
lose  their  shape;  while  they  effectually  resist  the  action  of  acids,  ether, 
and  chloroform. 


Fig.  204. — Actinomycosis  of  Liver.    A,  actinomyces;    B,  polymorphonuclear 
leucocytes;    C,  nuclei  of  liyer-cells. 


Clinical  experience  and  bacteriological  research  appear  to  prove  that 
infection  in  animals  and  man  can  take  place  with  fragments  of  actino- 
myces, and  that  the  resulting  pathological  conditions  are  the  same  as 
when  the  whole  fungus  is  inserted  into  the  tissues.  Gross  observed  the 
polymorj)hous  character  of  the  actinomyces  which  could  present  them- 
selves in  the  form  of  single  bacilli  or  rods,  while  the  well-known  club 
shapes  were  absent.  Ponfick  has  regarded  the  fungus  as  a  polymorphous 
bacterium  since  1851.  He  is  agreed  as  to  the  influence  of  particles  of  the 
fungus  in  the  production  of  the  disease,  and  in  support  of  this  view  re- 
lates the  case  of  a  boy  who  had  swallowed  a  bristle.  Some  months  later 
an  actinomycotic  abscess  formed  upon  the  back,  in  which,  on  opening, 
the  bristle  was  found. 

Staining-. — For  staining  the  actinomyces,  Weigert  uses  Wedl's  orseille; 
Marchand,  eosin:    Dunker  and  Magnussen,  cochineal-red:    iloosbrugger. 


DESCEIPTIOX    OF'  TUXGUS.  623 

hfematoxylm-alimi;  and  Partsch^  in  section-staining,  lias  liacl  the  best  re- 
sults with.  Gram's  method.  Babes  has  made  beautiful  dry  preparations 
by  using  a  2-per-cent.  solution  of  safranin  in  aniline-oil,  followed  by  treat- 
ment with  iodide  of  potassium. 

0.  Israel  has  found  that  a  solution  of  orcein  in  ^cetic  acid  stains  the 
rays  a  Bordeaux  red,  while  the  filaments,  if  decolorization  is  not  carried 
too  far,  present  a  blue  tinge.  Baranski  uses  picrocarmine  for  staining 
fresh  preparations  of  actinomyces  bovis.  A  small  amount  of  the  contents 
of  a  yellow  nodule,  or  pus  from  the  part,  is  spread  in  a  thin  layer  on  a 
cover-glass  and  dried  in  the  air.  The  cover  is  then  passed  three  times 
through  the  flame  of  an  alcohol-lamp,  care  being  taken  not  to  overheat 


Fig.    205.— Actinomyces  from   a   Section   of   a  MaxiUary  Tumor   of   a   Cow.      (Weigert's 
method.    Orseille  and  gentian-violet.    Zeiss  Via  o.i.,  ocular  4.)     {After  Crookshank.) 

the  preparation.  It  is  then  floated  in  the  picrocarmine  solution,  or  a  few 
drops  of  the  staining  fluid  are  placed  on  the  cover.  The  whole  process  of 
staining  is  completed  in  two  or  three  minutes.  The  cover  is  then  care- 
fully washed  by  agitating  it  in  distilled  water  and  alcohol,  and  examined 
in  water  and  glycerin.  The  fungus  takes  a  yellow  color,  while  the  re- 
maining structure  appears  red. 

The  polymorphous  variety  can  be  successfully  stained  by  Gram's 
method. 

Cultivation  Experiments. — It  has  been  found  extremely  difficult  to 
cultivate  the  actinomyces  outside  of  the  body,  probably  on  account  of 
the  usual  culture-media  not  being  well  adapted  for  its  growth.  The  first 
successful  experiments  were  made  in  1886  by  Bostrom,  of  Giessen,  upon 


G24  PRINCIPLES    OF    SUEGEEY. 

plates  of  coagulated  blood-serum  and  agar-agar^  the  fungus  attaining  its 
maturity  in  five  or  six  days^  when  it  presented  the  ty])ical  structure  of 
actinomycosis  as  found  in  man.  0.  Israel  cultivated  the  fungus  success- 
fully upon  coagulated  blood-serum.  Upon  this  medium  the  culture  grows 
very  slowly  and  the  fungus  often  undergoes  calcifieation.  Israel  made 
the  observation  that  water,  glycerin,  blood-serum,  and  weak  saline  solu- 
tions seriously  impair  the  vitality  of  the  fungus,  and  he  maintained  that 
the  effect  of  these  agents  on  the  actinomyces  explains  the  failure  of  pre- 
vious culture  and  inoculation  experiments.  If  evaporation  is  prevented,  a 
thin,  velvety  layer  forms  on  the  surface  of  the  blood-serum  in  about  eight 
weeks,  in  the  vicinity  of  which,  not  before  the  expiration  of  fourteen  days, 
cell-nodules  appear  more  in  a  downward  direction  than  on  the  sides  of  the 
inoculation-streak.  From  the  tenth  to  the  fourteenth  day  numerous 
spores  are  produced  and  a  thick  wall  of  club-shaped  mycelia  in  typical 
centrifugal  arrangement. 

At  a  meeting  of  the  medical  society  of  Berlin,  March  5,  1890,  M. 
Wolff  made  a  communication  in  which  he  described  culture  experiments 
with  actinomyces  which  he  made  jointly  with  James  Israel.  He  an- 
nounced that  they  had  succeeded  in  cultivating  the  fungus  in  and  upon 
coagulated  albumen  of  egg  and  agar-agar.  The  material  used  was  taken 
from  a  case  of  retromaxillary  actinomycosis  immediately  after  the  abscess 
was  incised.  With  the  yellow  granules  stab  and  streak  inoculations 
were  made,  using  agar-agar  as  a  soil.  It  was  found  that  the  actinomyces 
is  not  a  purely  anaerobic  fungus,  as  it  grew  upon  the  surface  as  well  as 
in  the  depth  of  the  culture-soil.  The  agar  culture  appeared  first  as  trans- 
parent little  drops,  which,  by  confluence,  made  an  opaque,  white  mass. 
Under  the  microscope  the  culture  was  seen  to  be  composed  of  short,  thick 
rods,  with  an  admixture  of  other  elements.  The  egg  cultures,  on  the 
other  hand,  were  made  up  of  short,  thick  rods  besides  a  mass  of  threads, 
some  of  them  twisted  in  the  shape  of  a  cork-screw,  presenting  an  in- 
tricate net-work  of  threads.  •  With  these  cultures  successful  inoculation 
experiments  were  made.  The  nutrient  medium  that  yields  the  best  re- 
sults and  is  now  in  general  use  is  glycerin-agar. 

Inoculation  Experiments, — In  1883  James  Israel  succeeded  in  pro- 
ducing the  disease  artificially  in  a  rabbit  by  introducing  a  fragment  of 
actinomycotic  tissue  into  the  peritoneal  cavity.  SomeAvhat  later  Ponfick 
made  successful  inoculation  experiments  in  calves  by  implantation  of  in- 
fected granulation-tissue  under  the  skin  into  the  abdominal  cavity  or 
directly  into  veins.  Eotter  experimented  on  calves,  pigs,  dogs,  guinea- 
pigs,  and  rabbits,  and  in  only  one  instance,  a  rabbit,  did  he  succeed  in 
reproducing  the  disease.  In  this  case  a  piece  of  granulation-tissue  the 
size  of  a  bean  was  inserted  into  the  peritoneal  cavity,  and  the  animal. 


SOUECES    OF    INFECTION.  625 

having  manifested  no  symptoms  of  disease,  was  killed  six  months  after 
the  inoculation.  On  opening  the  abdominal  cavity,  about  twenty  nodules, 
varying  in  size  from  the  head  of  a  pin  to  a  hazel-nut,  were  found  dis- 
tributed over  a  considerable  surface  around  the  graft,  each  of  them 
showing  the  typical  histological  structure  of  actinomycosis.  The  trans- 
planted piece  of  tissue  was  found  perfectly  capsulated  in  one  of  the 
nodules  the  size  of  a  bean.  As  the  fungus  was  found  in  all  the  nodules, 
it  is  only  reasonable  to  conclude  that  the  disease  spread  from  the  original 
focus  by  migration  of  some  of  the  new  fungi,  which,  at  their  respective 
points  of  localization,  established  independent  centres  of  infection  and 
tissue-proliferation.  While  the  actinomyces  in  the  new  nodules  presented 
a  perfect  structure,  and  could  be  readily  stained,  the  transplanted  fungus 
in  the  graft  had  lost  its  structure,  and  could  no  longer  be  stained.  The 
first  successful  inoculation  experiments  with  pure  cultures  were  made 
by  Wolff  and  James  Israel.  Three  rabbits  were  inoculated  by  injecting 
a  pure  culture  into  the  peritoneal  cavity.  The  post-mortem  showed 
numerous  nodules  upon  the  parietal  peritoneum,  the  omentum,  and  be- 
tween the  intestinal  coils.  The  nodules  varied  in  size  from  the  head  of  a 
pin  to  that  of  a  hazel-nut,  and  each  of  them  was  surrounded  by  a  fibrous 
capsule.  The  interior  of  each  nodule  was  composed  of  a  yellow  mass  the 
consistence  of  tallow.  Typical  actinomycetes  were  found  imbedded  in 
masses  of  round  cells  in  a  state  of  fatty  degeneration. 

In  a  later  series  of  experiments  the  same  author  inoculated  23 
animals  with  a  pure  culture  grown  upon  sterilized  agar-agar.  Of  the  in- 
oculated animals,  18  were  rabbits,  3  guinea-pigs,  and  1  sheep.  In  most 
of  them  it  was  done  in  the  peritoneal  cavity.  In  every  instance  the 
result  was  positive  except  in  the  sheep.  Pure  cultures  were  made  from 
the  inoculation  product.  At  the  Tenth  International  Medical  Congress 
Gross,  of  Krakau,  reported  a  case  of  actinomycosis  of  the  sternum,  with 
the  pus  of  which  he  had  made  an  inoculation  into  the  anterior  chamber 
of  the  eye,  with  positive  results.  At  the  same  meeting  Hanau  stated 
that  he  had  inoculated  the  anterior  chamber  of  the  eye  with  actinomy- 
cotic material,  mth  the  same  positive  results. 

SOUECES  OF  INFECTION. 

As  regards  the  history  of  the  parasite  outside  the  body,  as  yet  only 
a  few  facts  are  known.  It  is  found  in  pig-meat,  and  is  peculiarly  sus- 
ceptible to  outside  influences.  Virchow  found  the  fungus  as  a  small,  cal- 
careous concretion  in  the  muscle-fibres  of  the  pig,  and  considered  its  flesh 
highly  dangerous  as  food  unless  well  cooked.  As  the  actinomycetes  found 
in  man  and  beast  resemble  each  other  morphologically  and  in  their  effect 
on  the  tissues,  as  well  as  in  their  reaction  to  chemical  substances,  it  is 


626  PRINCIPLES    OF    SUEGEEY. 

evident  that  the  etiology  of  the  disease  is  similar  in  both.  The  fungus 
has  never  been  found  outside  of  the  body.  Israel  is  of  the  opinion  that 
both  man  and  animals  are  infected  from  the  same  source,  such  as  veg- 
etables or  water.  Jensen  traced  an  epidemic  in  Seeland  to  the  eating  of 
rye  grown  on  land  recently  reclaimed  from  the  sea;  and  Johne  discovered 
a  fungus  closely  resembling  the  actinomyces  in  grains  of  rye  stuck  in  the 
tonsils  of  pigs.  That  the  ears  of  barley  or  rye  are  sometimes  the  carriers 
of  the  fungus  is  well  illustrated  by  the  case  reported  by  Soltmann.  The 
patient  was  a  boy  who  had  swallowed  an  awn  of  barley.  The  foreign  body 
lodged  in  the  pharynx,  where  it  gave  rise  to  difficulty  in  deglutition;  after- 
ward it  perforated  the  pharyngeal  wall, — an  accident  attended  by  hemor- 
rhage,^— and  later  an  actinomycotic  phlegmon  developed;  it  spread  rapidly, 
and  finally  opened  below  the  scapula.  Through  this  opening  the  foreign 
body  was  extracted.  Plana  examined  the  tongue  of  a  cow  suffering  from  a 
circumscribed  actinomycosis  of  this  organ,  in  which  the  disease  could 
be  traced  to  a  similar  origin:  perforation  of  the  tissues  and  infection 
by  a  sharp  beard  of  an  ear  of  barley.  That  actinomycosis  prevails 
in  an  endemic  form  is  well  shown  by  the  investigations  of  Preusse.  He 
examined  244  cattle  and  found  33  affected  by  some  form  of  the  disease. 
He  attributes  the  affection  to  feeding  the  cattle  Avith  straw  and  hay  that 
had  been  spoiled  by  submersion.  He  was,  however,  not  able  to  find  the 
fungus  in  the  fodder.  Actinomycosis  has  as  yet  only  been  found  among 
herbivorous  and  omnivorous  animals,  including  man,  and  the  frequent 
location  of  the  primary  swelling  in  the  mouth  seems  to  indicate  that  the 
fungus  gains  entrance  with  food.  Infection  in  man  usually  takes  place 
through  the  tonsils,  carious  teeth,  punctured  wounds,  by  inhalation  and 
ingestion  of  food  containing  the  fungus  in  an  active  state. 

PATHOLOGY  AND   MOEBID   ANATOMY. 

As  to  the  manner  in  which  the  fungus  exerts  its  pathogenic  action 
much  yet  remains  to  be  ascertained.  The  most  striking  effect  is  the  trans- 
formation of  mature  connective  tissue  into  embryonal  or  granulation- 
tissue.  The  fungus  possesses  no  pyogenic  properties.  It  gives  rise  in  the 
tissues  to  a  low  grade  of  chronic  inflammation,  and  becomes  imbedded  in 
the  specific  product  of  tissue-proliferation:   granulation-tissue. 

The  product  of  inflammation  around  each  fungus  consists  of  granu- 
lation-tissue, which,  under  the  microsco23e,  might  be  easily  mistaken  for 
tubercle  or  sarcoma  tissue.  At  first  the  cells  are  round;  at  a  later  stage 
of  the  inflammation  epithelioid  and  giant  cells  are  formed  immediately 
around  the  fungus.  Hoche  presents  a  study  of  the  histogenesis  of  the 
nodule  in  typical  actinomycosis.  The  essential  points  brought  out  are 
that  the  ray-fungus,  especially  when  of  feeble  virulence,  provokes  an  active 


PATHOLOGY   AND    MOEBID   ANATOMY. 


637 


phagocytosis  and  the  establishment  of  an  area  of  inflammation.  The 
gradual  extension  of  the  disease  is  caused  by  the  transportation  of  the 
mycelial  filaments  by  the  phagocytes.  The  absence  of  lymph-gland  com- 
plications is  due  to  the  accumulation  of  cells  about  the  periphery  of  the 
focus,  and  general  dissemination  occurs  only  through  the  invasion  of  the 
walls  of  blood-vessels.  As  the  disease  is  almost  always  attended  by  sup- 
puration at  some  time  during  its  course,  it  has  been  customary  to  ascribe 
to  the  actinomyces  pyogenic  properties.  Israel  has  always  held  that  the 
actinomyces  is  a  pus-producing  fungus,  in  opposition  to  Ponfick  and  other 
pathologists,  who  claim  that  when  suppuration  takes  place  it  is  the  result 
of  a  secondary  infection  with  pus-microbes.  As  cases  of  actinomycosis 
have  been  recorded  in  which  the  disease  remained  stationary  in  the  granu- 


Fig.  206. 


Fig.  207. 


Fig.  206.— Actinomycelial  Cluster  in  Giant  Cell;     Inoculation  of  Rabbit  with  the  Acid- 

Proof,  Atypical  Ray-fungus  of  Finger.     (Zeiss  Vi2>  ocular  4.)     {ScJiulze.) 

Fig.  207. — Giant  Cell  with  Actinomycelioid  Cluster.    From  a  renal  tubercle  fourteen  days 

after  injection  with  Moeller's  timothy  bacillus.     (Zeiss  V12.  ocular  2.)   (Lubarsch.) 

lation-stage,  for  an  indefinite  period  of  time,  without  suppuration  taking 
place,  and  pus-microbes  have  been  cultivated  from  the  pus  of  actinomy- 
cotic abscesses,  it  appears  more  than  probable  that  suppuration  occurred 
independently  of  the  presence  of  the  fungus,  and  was  produced  by  the 
specific  action  of  pus-microbes  on  the  granulation-tissue.'  Firket  asserts 
that  the  actinomyces  does  not  appear  to  produce  coagulation-necrosis,  but, 
from  a  study  of  the  earliest-formed  colonies,  he  finds  that  the  first  effect 
of  the  fungus  is  to  induce  cellular  hyperplasia.  It  is  as  if  the  tissue- 
elements  resented  the  intrusion  of  the  parasite,  which,  however,  mostly 
gains  the  upper  hand;  so  that  the  result  is  the  formation  of  granulation- 
tissue  and,  later,  abscesses  that  characterize  the   disease.     Suppuration 


628 


PEINCIPLES    OF    SUEGEEY. 


takes  place  earliest  when  the  disease  occujDies  a  location  where  secondary 
infection  with  pus-microbes  is  most  liable  to  occur.  As  a  rule,  it  may  be 
stated  that,  the  earlier  suppuration  takes  place,  the  more  rapid  is  the 
spread  of  the  disease  and  the  graver  the  prognosis;  while  the  absence  of 
suppuration  indicates  comparative  benignity,  and  points  in  the  direction 
of  a  more  chronic  form  of  the  affection. 

The  localized  chronic  form  of  actinomycosis  resembles,  in  its  clinical 
features  and  its  anatomical  locations,  more  closely  sarcoma  than  any  other 
affection,  and  is  most  frequently  mistaken  for  this  form  of  malignant 
growth.  In  such  cases  it  would  be  difficult,  if  not  impossible,  in  the  ab- 
sence of  the  specific  fungus,  to  make  a  differential  diagnosis  between  it 


Fig.  208.— Actinomyces:    Section  from  Actinomycotic  Swelling.     X  300.     (Flilgge.) 

and  round-celled  sarcoma,  even  by  a  most  careful  microscopical  examina- 
tion, as 'the  histological  structure  of  both  is  almost  identical. 


CLINICAL    VAEIETIES. 

If  infection  take  place  by  fully-developed  actinomycetes,  it  can  only 
do  so  by  the  fungus  or  its  granules  gaining  entrance  into  the  tissues 
through  some  loss  of  continuity  in  the  cutaneous  or  mucous  surface.  It 
has  been  claimed  that  infection  of  the  intestinal  mucous  membrane  can 
take  place  by  the  fungus  gaining  entrance  into  a  follicle  in  case  the  outlet 
of  the  latter  becomes  blocked  by  inflammation,  followed  by  rupture  and 
entrance  of  the  essential  cause  into  the  tissues.  In  the  cases  in  which 
no  primary  infection-atrium  could  be  found,  it  must  be  taken  for  granted 
that  the  local  lesion  had  healed  between  the  time  infection  took  place 


CLINICAL    YARIETIES.  639 

and  the  first  manifestations  of  the  disease^  or  that  infection  was  caused 
by  the  entrance  of  spores,  which,  from  their  smaller  size,  could  possibly 
find  their  way  into  the  tissues  through  intact  mucous  surfaces.  In  refer- 
ence to  the  primary  localization  of  the  disease,  Moosbrugger  gives  the  fol- 
lowing statistics:  In  29  cases  the  lower  jaw,  mouth,  and  throat  were 
affected;  in  9,  the  upper  jaw  and  cheek;  in  1,  the  tongue;  in  2,  the 
region  of  the  oesophagus;  in  11,  the  intestines;  in  14,  the  bronchial  tract 
and  the  lungs;  in  7  the  point  of  entrance  could  not  be  ascertained.  In- 
fection may  take  place  through  any  abraded  surface  brought  in  contact 
with  the  specific  cause,  and  for  clinical  purposes  the  cases  may  be  divided 
into  the  following  three  groups:  1.  Cutaneous  surface.  2.  Alimentary 
canal.    3.  Eespiratory  tract. 

1.  Cutaneous  Surface.  —  A  number  of  well-authenticated  cases  of 
primary  actinomycosis  of  the  skin  have  been  placed  on  record.  Monestie 
states  that  actinomycosis  affecting  the  skin  may  be  secondary  to  extensive 
visceral  invasion  or  may  be  local,  as  in  connection  with  the  inferior  max- 
illa. The  affection  is  most  common  in  the  face  and  next  on  the  hands; 
that  is,  in  localities  most  exposed  to  direct  infection.  It  manifests  itself 
in  two  forms:  the  gummatous  and  the  anthracoid,  the  former  presenting 
cavities  resembling  the  gummata  of  syphilis  or  of  tuberculosis,  containing 
pus,  each  abscess  communicating  with  the  surface  of  the  skin  through  a 
small  fistula.  The  anthracoid  variety  presents  numerous  fistulge,  which 
discharge  a  small  quantity  of  pus,  and  which  does  not  collect  at  any  one 
point.  A  pathognomonic  sign,  observed  by  Derville,  is  the  presence  of 
maculse  more  or  less  pronounced  according  to  the  color  of  the  surround- 
ing skin.  If  the  general  color  is  pale,  they  are  violaceous;  if  dark,  they 
are  black  or  bluish  gray.  The  spots  vary  in  size  from  a  pinhead  to  a  bean, 
and  present  a  central  whitish  point.  Partsch  describes  a  case  of  actino- 
mycosis developing  in  the  scar  left  after  extirpation  of  the  breast.  The  pa- 
tient was  a  man  aged  60  years.  In  June,  1884,  his  left  breast  was  removed 
for  an  ulcerating  carcinoma.  As  the  wound  did  not  heal  by  primary  union, 
'and  the  process  of  cicatrization  was  very  slow,  a  number  of  small  skin- 
grafts  from  a  perfectly  healthy  young  man  were  transplanted.  The  wound 
was  practically  healed  in  September.  Two  months  later  the  cicatrix  ulcer- 
ated and  an  abscess  discharged  itself.  Actinomycetes  were  found  in  the 
pus.  The  parts  were  excised,  and  the  progress  of  the  disease  was  ap- 
parently arrested.  No  explanation  could  be  made  as  to  how  the  infection 
occurred.  Hochenegg  reported  a  case  of  primary  actinomycosis  of  the 
skin  in  the  left  submaxillary  region.  He  attributed  the  disease  to  an  in- 
vasion of  the  fungus  through  a  small  atheroma. 

In  Kaposi's  case,  when  the  disease  was  first  noticed,  it  appeared  as 
a  red  spot,  the  size  of  a  florin,  on  the  left  pectoral  muscle,  which  gradu- 


630  PRINCIPLES    OF    SURGERY. 

ally  increased  to  the  size  of  a  walnut  and  then  gradually  flattened  down 
and  disap23eared.  Meanwhile,  fresh  spots  and  lumps  appeared,  some  as 
large  as  a  pigeon's  egg.  Eleven  years  after  the  beginning  of  the  disease 
a  swelling  as  large  as  an  apple  appeared  over  the  spine  of  the  sixth  ver- 
tebra, which  gradually  extended  forward  and,  a  year  later,  formed  a  large 
tumor  behind  the  right  axilla.  A  year  later  this  swelling  had  diminished 
in  size  to  that  of  a  pigeon's  egg,  and  then  again  increased  in  size.  Ulcera- 
tion set  in,  exposing  a  fungous,  bleeding  surface.  At  this  time  the  entire 
trunk,  but  not  the  limbs,  was  covered  with  nodules,  spots,  and  stripes. 
The  infiltration  was  located  in  the  corium.  This  case  is  remarkable  for 
the  chronicity  of  the  disease,  the  multiple  points  of  regional  infection, 
and  the  limitation  of  secondary  infection  with  pus-microbes  to  a  few  iso- 
lated nodules. 

At  the  meeting  of  the  German  Society  of  Surgeons,  in  1889,  Leser 
reported  3  cases  of  primary  actinomycosis  of  the  skin  that  had  come 
under  his  own  observation  in  the  course  of  a  single  year.  In  his  remarks 
on  this  subject  he  placed  special  stress  on  the  manner  in  which  the  dis- 
ease extends.  In  the  periphery  of  the  primary  lesion  he  found  numerous 
minute  nodules,  later  becoming  the  seat  of  destructive  changes,  resem- 
bling, in  this  respect,  the  clinical  features  of  tuberculosis  of  the  skin.  The 
extension  of  the  disease  in  the  direction  of  the  deep  tissues  takfes  place  by 
the  formation  of  passages  corresponding  to  the  size  of  a  lead-pencil;  these 
are  filled  with  yellowish-gray  or  reddish-gray  granulations,  which  attack 
and  destroy  tissues,  irrespective  of  their  anatomical  structure.  The  lym- 
phatic glands  were  always  found  intact.  Mueller  reports  two  cases  of 
actinomycosis  of  the  mammary  gland.  The  fungus  was  found  in  the  in- 
flammatory product  in  both  cases.  The  origin  is  obscure.  Each  had  re- 
ceived a  blow  upon  the  breast  and  in  both  cases  a  poultice  of  linseed  meal 
was  applied  after  the  incision  was  made. 

2.  Alimentary  Canal. — The  frequency  with  which  the  disease  affects 
the  mouth  and  jaws  of  cattle  is  explained  by  the  occurrence  of  numerous 
points  of  injury  caused  by  masticating  rough  food,  that  furnishes  the 
necessary  infection-atrium  through  which  the  fungus  invades  the  tissues. 
In  man  the  disease  has  been  observed  in  nearly  all  parts  of  the  alimentary 
canal. 

Teeth. — In  man  infection  takes  place  frequently  through  carious 
teeth,  and  through  abrasions  in  the  gums  and  mucous  membrane  of  the 
mouth.  Israel  found  the  fungus  in  the  cavities  of  carious  teeth,  and 
Partsch  detected  in  the  same  locality  almost  pure  cultures  without  any 
manifestation  of  disease  except  chronic  periodontitis.  The  fungus  occurs 
here  often  side  by  side  with  leptothrix. 

Tongue.  —  Hochenegg   saw   a  case   of   actinomycosis   of  the   tongue 


CLINICAL    VAKIETIES.  631 

caused  by  an  infected  carious  tooth.  The  swelling  was  the  size  of  a  cherry, 
located  near  the  apex  of  the  organ.  The  affection  had  existed  for  two 
months.  The  growth  was  excised,  and  on  examination  was  found  to  con- 
sist of  granulation-tissue,  with  a  central  yellow  mass  the  size  of  a  millet- 
seed.  Besides  this  case  3  other  cases  of  actinomycosis  of  the  tongue  are 
on  record:   1  primary,  1  secondary  to  disease  of  the  jaw,  and  1  metastatic. 

Jaws. — That  carious  teeth  furnish  a  frequent  infection-atrium  in 
maxillary  actinomycosis  is  well  known,  and  in  many  instances  the  disease 
in  its  early  stages  has  been  mistaken  for  an  ordinary  dental  affection,  and 
patients  have  often  sought  relief  at  the  hands  of  a  dentist.  The  lower 
jaw  is  most  frequently  affected,  the  growth  being  connected  with  the  bone 
or  situated  close  to  it,  or  it  has  already  extended  to  the  submental  or  sub- 
maxillary region.  The  disease  often  pursues  a  chronic  course,  closely 
simulating  periosteal  sarcoma,  until  it  reaches  the  loose  tissues  of  the  neck, 
when  rapid  extension  takes  place,  in  a  downward  direction,  along  the  sub- 
cutaneous connective  tissue  and  the  intermuscular  se]5ta.  Israel  refers  to 
a  case  in  which  the  actinomycotic  swelling  in  the  submaxillary  region  ex- 
tended, in  five  months  (August  to  December),  to  the  level  of  the  thyroid 
cartilage.  When  the  disease  is  primarily  located  in  the  upper  jaw,  which, 
however,  occurs  only  in  exceptional  cases,  it  tends  to  invade  rapidly  the 
adjacent  soft  parts,  and  even  to  implicate  the  base  of  the  skull  and  the 
brain.  The  prognosis  is  always  more  serious  when  the  disease  affects  the 
upper  than  the  lower  jaw,  as  the  tendency  here  to  invade  the  deep  struct- 
ure is  much  greater.  Two  cases  of  actinomycosis  in  man  have  come  under 
my  observation,  and  as  both  of  them  originated  in  the  mouth,  and  repre- 
sent, from  a  prognostic  point  of  view,  two  distinct  classes,  I  will  describe 
them  briefly.  Since  the  second  edition  made  its  appearance  a  number  of 
cases  have  come  under  my  observation  at  the  clinic  of  Eush  Medical  Col- 
lege, among  them  two  cases  of  intestinal  actinomycosis. 

The  first  patient  was  a  man  30  years  of  age,  German  by  birth,  and 
a  soda-water  manufacturer  by  occupation.  His  business  required  him  to 
make  frequent  trips  into  the  country  by  team.  He  had  no  recollection 
of  having  come  in  contact  with  cattle  suffering  from  "swelled  head"  or 
"lumpy  jaw."  During  the  winter  of  1886  he  suffered  from  what  he  sup- 
posed was  an  ordinary  cold;  the  right  side  of  the  lower  jaw  was  swollen 
and  painful.  As  one  of  the  molar  teeth  showed  evidences  of  decay  and 
had  become  loose,  it  was  extracted.  The  pain  and  swelling,  however,  did 
not  improve,  and  the  attending  physician  extracted  all  of  the  molar  teeth 
of  the  lower  jaw  on  that  side.  At  this  time  a  fungous  mass  commenced 
to  appear  over  the  surface  of  the  edentulous  bone.  The  cheek  on  the 
affected  side  was  also  greatly  swollen.  The  patient  was  admitted  into  the 
hospital  about  six  months  after  the  first  symptoms  had  appeared.     At 


633  .  PEINCIPLES    OF    SUEGERY. 

this  time  the  lower  jaw^  in  the  mouth,  presented  a  fungous  mass  extending 
from  the  angle  of  the  bone  to  the  first  bicuspid;  the  swelling  extended 
as  far  as  the  tonsil.  The  cheek  was  enormously  swollen  from  the  angle  of 
the  mouth  to  the  lower  margin  of  the  parotid  gland.  The  skin  over  the 
swollen  part  presented  a  pale,  glossy  ajopearance,  and  the  superficial  veins 
were  considerably  dilated.  Around  the  margin  of  the  swelling  no  distinct 
border-line  could  be  felt,  the  infiltrated  parts  fading  gradually  into  the 
healthy  surrounding  tissues.  Free  suppuration  from  the  surface  of  the 
fungous  granulations,  and  a  number  of  small  abscesses  had  discharged 
themselves  into  the  cavity  of  the  mouth.  As  some  doubt  existed  as  to  the 
character  of  the  inflammation,  careful  and  repeated  examinations  were 
made  of  the  jdus  removed  from  the  small  abscess-cavities,  and  on  several 
occasions  fragments  of  actinomyces  were  found.  The  discovery  of  the 
specific  cause  of  the  inflammation  cleared  up  the  diagnosis  and  furnished 
an  urgent  indication  for  operative  treatment.  An  incision  was  made  along 
the  lower  border  of  the  jaw  from  just  below  the  articulation  to  near  the 
symphysis,  and,  after  arresting  all  haemorrhage,  it  was  carried  into  the 
cavity  of  the  mouth.  The  alveolar  processes  of  the  jaw  were  affected,  and 
were  removed  with  chisel  and  cutting-forceps.  Wherever  the  periosteum 
showed  signs  of  infiltration  it  was  carefully  scraped  away,  and  finally  the 
whole  bone-surface  was  thoroughly  cauterized.  The  infiltrated  soft  tissues 
were  dissected  out  with  knife  and  scissors;  the  disease  was  found  to  have 
extended  as  far  as  the  tonsil.  The  bottom  of  the  wound  was  iodoformized 
and  packed  with  iodoform  gauze,  while  the  external  wound  was  sutured. 
The  entire  external  wound  healed  by  primary  union,  and  the  cavity  in  the 
mouth  closed  slowly  by  granulation.  The  patient's  general  health  con- 
tinued to  improve  rapidly,  nntil  six  weeks  after  the  operation,  when  the 
neck  below  the  scar  became  swollen,  followed  in  a  short  time  by  the  forma- 
tion of  abscesses  reaching  from  the  angle  of  the  jaw  to  the  clavicle,  and 
posteriorly  as  far  as  the  spine  of  the  scapula.  ISTumerous  openings  were 
made  and  efficient  drainage  established,  but  suppuration  continued  nn- 
abated,  and  the  patient  became  extremely  emaciated.  The  suppurative 
inflammation  extended,  and  four  months  after  the  first  operation  the  pa- 
tient died;  the  symptoms  during  the  last  days  of  life  pointed  to  an  hypo- 
static pneumonia.  Actinomycetes  were  constantly  found  in  the  pus  dur- 
ing the  entire  course  of  the  disease.  I  believe  that  the  recurrence  of  the 
disease  was  due  to  imperfect  removal  of  infected  tissues  in  the  posterior 
and  lower  portion  of  the  pharynx. 

The  second  case  came  under  my  care  during  the  summer  of  1887. 
The  patient  was  a  young  man,  employed  on  a  farm.     About  five  months 
before  he  was  admitted  into  the  hospital  he  had  a  number  of  teeth  ex- ' 
tracted  from  the  right  upper  jaw,  under  the  belief  that  the  teeth,  some  of 


CLIXICAL    VARIETIES.  633 

which  were  decayed,  were  the  cause  of  the  pain  and  swelling  in  that  region. 
The  physician  in  attendance  diagnosed  sarcoma  of  the  upper  jaw,  and 
sent  the  case  to  me  for  operation.  On  my  first  examination,  I  found  a 
swelling  involving  the  right  side  of  the  face,  extending  from  the  zygo- 
matic arch  to  near  the  lower  border  of  the  lower  jaw,  involving  the  deep 
tissues,  and  connected  with  the  alveolar  processses  of  the  posterior  portion 
of  the  upper  jaw.  The  swelling  was  firm  and  without  well-defined  mar- 
gins. No  evidences  of  suppuration.  The  history  of  the  case,  and  particu- 
larly the  location,  extent,  and  physical  properties  of  the  swelling,  led  me 
to  the  opinion  that  it  was  the  result  of  actinomycotic  infection.  All  in- 
fected tissue  was  thoroughly  excised  through  a  large  external  incision,  the 
jaw-bone  scraped  and  cauterized.  The  entire  thickness  of  the  cheek,  with 
the  exception  of  the  skin  and  superficial  fascia,  appeared  to  be  transformed 
into  granulation-tissue.  In  the  granulations  numerous  minute  yellowish- 
gray  bodies  were  found,  which,  under  the  microscope,  showed  the  typical 
structure  of  the  ray-fungus.  The  mycelia  were  not  so  bulbous  as  we  find 
them  pictured  in  the  books,  but  the  distal  extremity  appeared  to  be  sur- 
rounded by  dust-like  bodies,  presenting  the  appearance  of  a  small  brush. 
These  minute  granules  I  regarded  as  spores.  In  the  first  case,  in  which 
suppuration  had  taken  place,  I  never  succeeded  in  finding  the  actino- 
myces  perfect  and  complete;  in  the  second  case  the  granulation-tissue  had 
not  been  destroyed  by  suppuration,  and  the  fungus  was  found  in  a  perfect 
condition  and  in  a  state  of  fructification.  These  cases  present  a  striking 
contrast,  both  in  regard  to  the  local  condition  and  the  ultimate  termina- 
tion. In  the  first  case  secondary  infection  with  pus-microbes  had  already 
taken  place,  and  the  phlegmonous  inflammation  that  followed  this  occur- 
rence prepared  the  tissues  again  for  the  diffusion  of  the  actinomycotic 
process;  while  in  the  second  case  the  inflammatory  process  had  not  passed 
beyond  the  granulating  stage,  and  the  boundary-line  between  healthy  and 
diseased  tissue  was  also  more  distinctly  marked:  a  most  important  factor 
in  the  operative  treatment.  The  first  patient  died  from  recurrence  of  the 
disease  in  the  vicinity  of  the  operation  wound  and  its  extension  to  the  neck 
and  chest;  while  in  the  second  case  the  wound  healed,  and  the  patient  has 
remained  in  perfect  health  since. 

3.  Intestinal  Canal. — In  primary  intestinal  actinomycosis  the  disease 
is  caused  by  ingress  of  the  fungus  with  food  or  water,  and  its  implanta- 
tion upon  the  mucous  surface.  At  the  point  of  implantation  the  fungus 
multiplies,  and  by  its  growth  invades  the  submucous  tissue,  which  becomes 
the  seat  of  active  tissue-proliferation.  Arrest  and  implantation  of  the 
actinomycetes  are  determined  by  antecedent  pathological  changes.  Chiari 
has  given  an  excellent  account  of  the  pathological  condition  found  in  a 
case  of  intestinal  actinomycosis  that  came  under  his  observation.     The 


634  PEINCIPLES    OF    SUEGEEY. 

patient  was  a  man^,  36  years  of  age,  who  during  life  presented,  as  the  most 
prominent  clinical  feature,  progressive  marasmus.  At  the  necropsy 
chronic  tuberculosis  in  the  apices  of  the  lungs  and  a  few  tubercular  ulcer- 
ations in  the  lower  portion  of  the  ileum  were  found.  The  large  intestine 
presented  a  very  remarkable  appearance,  the  mucous  membrane  of  which, 
except  the  caecum  and  ascending  colon,  was  covered  with  whitish  deposits, 
forming  round  and  oblong  patches,  some  of  them  1  cubic  centimetre  in 
diameter  and  5  millimetres  in  thickness.  In  some  of  these  patches  could 
be  seen  minute  yellowish-brown  and  yellowish-green  granules.  The 
patches  were  firmly  adherent,  and  when  removed  left  a  loss  of  substance 
in  the  mucous  membrane.  The  mucous  membrane  throughout  was  in  a 
state  of  catarrhal  inflammation.  On  microscopical  examination  the  gran- 
ules proved  to  be  actinomycetes.  The  mycelium  had  penetrated  into  the 
tubular  glands  and  showed  calcified,  club-shaped  conidia.  The  calcifica- 
tion of  the  club-shaped  extremities  had  undoubtedly  prevented  deeper 
penetration  of  the  fungus.  Hochenegg  presented  a  case  of  actinomycosis 
to  the  Medical  Society  of  Vienna  in  a  man,  43  years  of  age,  who  had  sus- 
tained an  injury  of  the  abdomen  nine  months  previously,  and  had  since 
that  time  noticed  a  painful  swelling  at  the  seat  of  injury.  In  the  region  of 
the  umbilicus  a  fistulous  opening  formed,  which  continued  to  discharge  a 
thin  secretion,  in  which  the  actinomyces  was  constantly  found.  The  patient 
was  very  much  emaciated  and  many  of  the  teeth  were  carious.  There  w^as 
no  swelling  about  the  jaws  or  neck.  Examination  of  the  organs  of  the 
chest  and  the  sputum  revealed  no  additional  diagnostic  information.  The 
author  expressed  the  opinion  that  the  inflammatory  swelling  caused  by  the 
contusion  furnished  the  necessary  conditions  for  the  localization  of  the 
actinomyces  from  the  intestinal  canal. 

Zemann  reports  5  cases  of  actinomycosis  of  the  abdomen.  In  4  of 
them  the  disease  commenced  with  sharp,  lancinating  pains  in  the  abdo- 
men, and  during  their  course  presented  the  clinical  picture  of  chronic 
peritonitis.  Swellings  could  be  found  in  one  or  more  places  in  the  an- 
terior abdominal  wall,  and  the  abscesses  Avere  either  incised  or  opened 
spontaneously,  and  in  3  cases  they  communicated  with  the  intestinal 
canal.  The  first  case  was  a  woman,  30  years  of  age,  who  had  a  fistulous 
opening  in  the  anterior  abdominal  wall  which  communicated  with  a  swell- 
ing in  the  left  parametrium.  The  patient  stated  that  this  swelling  ap- 
peared soon  after  her  last  childbed.  A  constant  discharge  of  yellowish-red 
pus  was  maintained,  in  which,  under  the  microscope,  numerous  actino- 
myces could  be  seen.  The  patient  died  of  exhaustion,  and  at  the  post- 
mortem chronic  para-  and  peri-  metritis  were  found,  with  extensive  pus- 
cavities  that  communicated  with  the  rectum  and  bladder.  The  second 
case  occurred  in  a  person,  18  years  of  age,  who,  during  life,  had  suffered 


CLINICAL    VAEIETIES.  635 

from  a  large  abscess  in  the  abdominal  cavity,  under  the  right  lobe  of  the 
liver,  which  communicated  with  the  intestinal  canal,  and  had  led  to 
numerous  fistulous  openings  in  the  anterior  abdominal  wall. 

At  the  necropsy  a  loop  of  the  ileum  was  found  perforated  and  in 
communication  with  the  abscess-cavity.  The  pus  contained  numero^us 
actinomycetes.  In  the  third  case  the  diagnosis  was  made  post-mortem  by 
the  discovery  of  the  actinomyces  in  the  pus.  The  disease  was  located  in  the 
lower  portion  of  the  ileum  and  caecum,  where  it  had  caused  suppuration 
and  numerous  adhesions.  A  most  remarkable  and  interesting  history 
is  connected  with  the  fourth  case.  A  robust,  well-nourished  woman,  40 
years  of  age,  was  attacked  quite  suddenly  with  pain  in  the  stomach,  high 
temperature,  diarrhoea,  and  vomiting,  followed  by  cerebral  symptoms  and 
death.  At  the  necropsy  the  right  Fallopian  tube  was  found  transformed 
into  a  large  abscess,  both  extremities  of  the  tube  closed,  and  walls  of  sac 
lined  with  granulations  containing  the  actinomyces.  The  fifth  patient  was 
50  years  of  age,  and  had  suffered  for  a  long  time  from  lancinating  pain 
in  the  abdomen;  a  fistulous  opening  formed  in  the  umbilical  region  and 
discharged  a  thin,  yellowish-green  pus.  The  post-mortem  showed  actino- 
mycosis of  the  peritoneum,  small  intestine,  left  ovary,  and  liver;  large 
abscess  among  the  intestinal  coils;  perforation  of  small  intestine  and 
bladder.  In  the  uj)per  part  of  the  small  intestine  small  pigmented  cica- 
trices were  found.  In  all  of  the  above  cases  the  microscopical  examina- 
tion revealed  the  presence  of  the  fungus  in  the  granulation-tissue  as  well 
as  in  the  pus  of  the  abscess-cavities.  In  a  case  of  intestinal  actinomycosis 
reported  by  Langhans,  the  disease  started  evidently  from  the  appendix 
vermiformis,  4  centimetres  in  length,  the  end  of  which  appeared  as  if 
transversely  cut  in  an  abscess-cavity  the  size  of  a  walnut.  The  abscess 
was  on  the  right  side  of  the  bladder,  and  so  deep  in  the  pelvis  that  during 
life  it  could  not  be  located.  The  abscess  pursued  a  chronic  course,  and 
the  walls  were  well  defined;  no  signs  of  chronic  or  acute  peritonitis. 
Furthermore,  the  mucous  membrane  of  the  appendix  was  studded  with 
cicatrices,  and  presented  a  slate  color.  The  principal  seat  of  the  actino- 
mycotic process  was  in  the  liver.  In  a  second  case  reported  by  the  same 
author  the  clinical  course  of  the  disease  resembled  perityphlitic  abscess. 
The  necropsy  showed  perforation  of  the  csecum  and  ascending  colon.  No 
cicatrices  in  the  mucous  membrane  or  surrounding  tissues.  In  all  prob- 
ability, the  perforations  occurred  from  without  inward. 

Luening  and  Hamm  have  reported,  with  interesting  details,  a  case 
of  primary  actinomycosis  of  the  colon  with  metastatic  deposits  in  the 
liver.  The  patient  was  a  man  28  years  of  age,  who,  in  1880,  suffered  from 
an  acute  abdominal  affection,  which  at  the  time  was  diagnosed  as  typhlitis. 
Four  years  later  a   second   attack   occurred,   attended  by   symptoms   of 


636  PRINCIPLES    OF    SUEGERY. 

intestinal  obstruction.  Patient  was  very  ill  for  eight  days^  when  the 
symptoms  of  obstruction  subsided,  and  he  made  a  slow  recovery.  During 
the  year  1887  he  had  a  third  attack,  attended  by  high  fever  and  absolute 
constipation  for  eight  to  ten  days.  During  the  month  of  December  of 
the  same  year  he  had  another,  but  less  severe,  attack,  and  at  this  time 
a  hard  swelling  made  its  appearance  in  the  right  side  of  the  abdomen. 
From  this  time  until  he  was  admitted  into  the  hospital,  April  5,  1888, 
he  was  confined  to  bed.  The  patient  was  at  this  time' greatly  emaciated, 
with  a  temperature  of  from  38.4°  C.  to  39.8°  C.  Swelling  the  size  of  a 
fist  in  the  right  side  of  the  abdomen,  half-way  between  umbilicus  and 
anterior  superior  spine  of  the  ileum.  Externally  this  swelling  presented 
redness  and  oedema.  Fluctuation  indistinct.  Deep  palpation  showed  that 
the  swelling  extended  to  right  hypochondrium;  abdomen  not  tympanitic. 
Swelling  painful  and  tender,  pain  extending  to  spermatic  cord  and  testicle 
on  same  side.  A  few  days  later  abscess  was  incised,  and  nearly  a  quart 
of  brownish  pus,  having  a  fgecal  odor,  escaped.  Digital  exploration  re- 
vealed an  irregular  cavity,  whose  walls  at  some  points  were  plainly  lined 
with  intestinal  coils.  Disinfection  and  drainage.  As  the  symptoms  did 
not  improve  materially,  the  abscess-cavity  was  again  scraped  out  and  dis- 
infected four  weeks  later.  After  the  second  operation  it  was  noticed 
that  the  pus  contained  yelloAV  granules,  which,  under  the  microscope,  were 
shown  to  be  actinomyces.  The  abscess  was  incised  a  third  time,  but  the 
patient  kept  losing  ground,  and  died  October  9th.  The  autopsy  revealed 
primary  actinomycosis  of  the  ascending  colon,  with  multiple  fistulous 
perforations.  A  metastatic  actinomycotic  abscess  of  the  liver  had  per- 
forated into  the  hepatic  vein,  resulting  in  multiple  metastases  in  the  lungs. 
The  cases  of  intestinal  actinomycosis  reported  above  warrant  the  opinion 
that  the  mucous  membrane  of  the  intestinal  canal  is  frequently  the  seat  of 
primary  localization  of  the  actinomyces,  thus  corroborating  the  state- 
ments of  Johne  in  reference  to  this  disease  in  animals. 

BEONCHIAL   TUBES   AND   LUNGS. 

If  an  actinomyces  should  be  inhaled  with  the  inspired  air,  and 
should  become  implanted  upon  the  bronchial  mucous  membrane,  and 
find  favorable  conditions  for  its  growth,  the  granule  will  become  sur- 
rounded by  new  cells  derived  from  the  preexisting  epithelial  cells,  and 
thus  become  the  centre  of  a  minute  granuloma. 

By  multiplication  of  the  actinomyces  new  nodules  are  produced, 
around  each  of  which  the  preexisting  tissue  is  transformed  into  embryonal 
tissue,  which  in  time  is  destroyed,  resulting  in  suppuration  and  loss  of 
tissue.  Israel  reported  a  case  of  actinomycotic  abscess  of  the  lung  caused 
by  the  entrance  of  an  infected  tooth  into  the  air-passages.     In  this  in- 


BRON'CHIAL    TUBES    AND    LUNGS. 


637 


stance  the  fungus  was  conveyed  into  the  bronchial  tube  with  the  carious 
toothy  and  the  infected  foreign  body  became  the  centre  of  the  specific 
inflammation. 

Cases  of  primary  actinomycosis  of  the  lungs^  however,  have  been 
observed  where  no  such  direct  carrier  of  the  contagium  could  be  found, 
and  in  which  infection  must  have  occurred  by  the  direct  inhalation  of 
the  fungus  or  its  spores  with  the  inspired  air.  Szenasy  found,  in  the 
case  of  the  wife  of  a  butcher,  who  had  suffered  for  nine  years  from 
severe  pain  in  the  right  side  of  the  chest,  latterly  attended  by  a  severe 
cough,  in  the  right  mammary  region,  a  fluctuating  swelling,  the  size  of  a 
hen's  egg,  covered  with  normal  skin.  On  the  outer  side  of  this  swelling, 
in  the  intercostal  space  between  the  third  and  fourth  ribs,  another  swell- 
ing existed,  double  in  size  and  elongated  in  shape,  and  with  indistinct 
margins.  This  latter  swelling  had  been  noticed  for  nine  years,  and  was 
tender  to  the  touch.     Auscultation  over  the  fourth  and  fifth  intercostal 


c  -V 


Fig.  209. — Actinomyces  from  Lung  of  Cow;  Fungus  in  the  Centre  of  Inflammatory 
Product.  A,  normal  epithelial  cells  of  bronchus  attached  to  connective  tissue;  B,  large 
epithelioid  cells;     G,   leucocytes.     X  350.      {Marchand.) 


spaces  on  the  healthy  side  revealed  bronchial  breathing  and  diffuse  bron- 
chial rales.  Temperature,  38.4°  C.  (101.1°  F.).  The  urine  contained  a 
trace  of  albumen.  By  aspiration  150  cubic  centimetres  of  thick,  yellow 
pus  were  removed,  and  contained  colonies  of  the  actinomyces.  Actinomyces 
were  also  found  in  the  sputum.  The  patient  had  carious  teeth,  but  no 
signs  of  actinomycosis  could  be  detected  in  the  mouth. 

Canali  relates  the  clinical  history  of  a  girl,  15  years  of  age,  who 
had  suffered  for  eight  years  from  a  cough,  attended  by  a  scanty,  fetid 
expectoration.  Inspection  and  percussion  yielded  only  negative  results. 
Auscultatory  symptoms  pointed  to  a  diffuse  catarrh.  Under  the  micro- 
scope the  sputum  was  seen  to  contain  pus-corpuscles,  epithelial  cells,  and 
numerous  actinomycetes.  ISTo  primary  source  of  infection  could  be  found 
in  the  mouth,  pharynx,  or  nose. 

Moosbrugger  interprets  the  mechanism  of  the  ingress  of  the  actinomyces 


G38  PKIXCIPLES    OF    SUEGEEY. 

by  assuming  that  the  fungus  enters  the  bronchial  tubes  during  inspiration, 
and  becomes  at  first  deposited  upon  the  mucous  membrane,  where  its 
presence  and  growth  cause  a  destruction  of  the  epithelial  cells,  when  it 
reaches  the  submucous  and  peribronchial  tissues,  in  which  a  nodule  of 
granulation-tissue  is  produced  that  by  pressure  induces  degenerative 
changes  and  gradual  destruction  of  the  bronchial  wall  for  further  infec- 
tion. He  belieyes  that  the  peribronchial  lymphatic  vessels  and  glands 
take  an  active  part  in  the  local  diffusion  of  the  process,  as  they  furnish 
an  avenue  for  the  dissemination  of  the  fungus  or  its  spores.  He  claims 
the  existence  of  an  actinomycotic  lymphangitis,  but  confesses  that  he 
has  never  seen  the  fungus  inside  of  lymphatic  vessels.  As  soon  as  the 
fungus  reaches  the  pulmonary  tissues,  it  gives  rise  to  parenchymatous  in- 
flammation, the  first  product  of  which  is  always  granulation-tissue,  which,  at 
a  later  stage,  and  under  the  influence  of  a  secondary  infection  with  pus- 
microbes,  undergoes  transformation  into  pus-corpuscles  and  the  formation 
of  abscesses. 

ACTIXOMYCOSIS    OF    BEAIX. 

Bollinger  placed  on  record  the  first  case  of  primary  actinomycosis  of 
the  brain.  The  patient  was  26  years  of  age.  The  intra  vitam  diagnosis 
was  tumor  of  the  brain;  the  most  prominent  symptoms  were  severe  head- 
ache, paralysis  of  left  abducens,  congestion  of  optic  papilla,  and  mo- 
mentary "unconsciousness.  The  swelling  in  the  brain,  found  on  autopsy, 
presented  the  characteristic  features  of  a  cystomysoma  in  the  third 
ventricle;  all  of  the  ventricles  were  found  considerably  dilated.  The  swell- 
ing contained  numerous  colonies  of  the  fungus  in  all  possible  stages  of 
development.  The  tendency  to  suppuration  of  the  tissues,  usually  found 
in  all  cases  of  actinomycosis  in  man,  was  entirely  absent  in  this  case. 
This  case,  if  any,  appears  to  be  one  of  cryptogenetic  infection,  as  the 
fungus  or  spores  must  have  entered  somewhere  through  the  cutaneous  or 
mucous  surface  without  producing  the  disease  at  the  primary  portio  in- 
nasionis,  and,  localizing  in  the  brain  by  embolism,  resulted  in  primary 
actinomycosis  in  this  organ. 

Keller  reported  a  case  of  metastatic  actinomycosis  of  the  brain  in 
which  a  correct  diagnosis  was  made  during  life.  The  patient  was  a 
middle-aged  woman,  who  suffered  from  pleurisy,  and  six  months  there- 
after an  abscess  developed  over  the  cartilages  of  the  sixth  and  eleventh 
ribs,  in  the  pus  of  which  actinomyces  were  found.  Two  years  later  in- 
creasing paresis  of  left  arm  developed,  followed  by  convulsions,  confined 
at  first  to  the  arm,  then  becoming  general,  and  at  times  identical  with 
cortical  epilepsy.  Diagnosis  of  actinomycosis  affecting  the  motor  area  was 
made;    operation  was  suggested  and  declined.     The  paresis  extended  tO' 


SYMPTOMS    AXD    DIAGNOSIS.  639 

left  lower  extremity  and  left  side  of  face;  later,  convulsions,  headache, 
vomiting,  and  loss  of  consciousness,  soon  deepening  into  coma.  Burger 
then  obtained  consent  to  operate.  The  patient  was  moribund,  and  re- 
quired no  anesthetic.  He  exposed  the  right  ascending  parietal  convolu- 
tion, incised  the  dura  mater  and  the  discolored  brain-surface,  and  removed 
2  ounces  of  thin,  greenish  pus,  in  which  were  found  actinomycetes  in  great 
abundance.  "When  the  pus  was  evacuated,  she  recovered  from  the  deep 
coma,  and,  while  still  on  the  operating-table,  called  for  water.  On  the 
following  day  consciousness  returned,  and  on  the  eighth  the  facial  paral- 
ysis disappeared.  In  two  months  the  wound  had  healed  and  the  paralytic 
lesions  improved,  but  there  remained  some  paresis  of  left  arm,  with  con- 
traction of  the  fingers.  In  less  than  one  year  there  was  a  recurrence  of 
the  symptoms,  and  Burger  reopened  the  brain-abscess,  followed  by  the 
escape  of  a  considerable  quantity  of  pus.  ISTo  material  improvement  fol- 
lowed, and  the  patient  died  a  few  days  thereafter. 

At  the  post-mortem,  the  middle  third  of  the  right  frontal  and  parietal 
convolutions  was  occupied  by  a  large  mass  of  newly-formed  tissue,  pro- 
truding over  the  surface  and  reaching  into  the  substance  of  the  brain 
for  one  inch.  Underneath  it,  deeply  buried  in  the  white  substance, '  an 
unopened,  capsulated  abscess,  the  size  of  a  nutmeg,  was  discovered. 

SYMPTOMS    AND    DIAGNOSIS. 

Actinomycosis  is  an  inflammatory  disease  that  clinically  is  noted  for 
its  chronicity.  The  specific  product,  composed  of  granulation-tissue,  is 
abundant,  and  the  swelling,  often  of  considerable  size,  resembles  more  a 
tumor  than  an  inflammatory  swelling.  The  extension  of  the  morbid 
process  takes  place  by  diffusion  of  the  ra3'-fungus  in  loco,  in  preference 
along  the  loose  connective-tissue  spaces,  each  fungus  constituting  a 
nucleus  for  a  nodule  of  granulation-tissue.  By  confluence  of  many  such 
nodules  the  inflammatory  swelling  often  attains  a  very  large  size,  and 
when  suppuration  occurs  in  the  interior  the  further  history  is  that  of 
chronic  abscess.  Eegional  dissemination  of  the  infective  process  never 
takes  place  through  the  lymphatic  glands.  When  the  lymphatic  struct- 
ures become  implicated,  it  is  an  indication  that  secondary  infection  has 
taken  place.  In  exceptional  cases  the  disease  pursues  quite  a  rapid  course, 
and  may  then  be  mistaken  for  an  acute  phlegmonous  inflammation,  osteo- 
myelitis, or,  when  diffused  over  a  large  surface  of  the  body,  for  syphilis. 
A  good  illustration  of  the  former  class  is  furnished  by  the  case  reported 
by  Kapper.  A  soldier,  22  years  of  age,  became  suddenly  ill  with  febrile 
symptoms  and  a  rapidly-increasing  swelling  of  the  lower  jaw.  An  early 
incision  was  made  and  liberated  a  large  quantity  of  pus.  which,  on  micro- 
scopical examination,  was  found  to  contain  the  actinomyces.    It  is  interesting 


640  PEINCIPLES    OF    SUEGERY. 

to  note  that  in  this  case  the  various  teeth  from  where  the  infection  had 
evidently  taken  place  contained  threads  of  leptothrix  and  the  actinomyces. 

At  a  meeting  of  the  Berlin  Medical  Society^  about  ten  years  ago,  0. 
Israel  gave  an  accurate  description  of  the  post-mortem  appearances  of 
a  case  of  diffuse  actinomycosis.  The  patient,  a  woman  44  years  of  age, 
had  been  treated  for  syphilis  in  one  of  the  surgical  clinics.  The  heart 
contained  a  number  of  minute  abscesses  containing  the  fungus  in  large 
numbers.  A  large  abscess  between  the  diaphragm,  stomach,  and  spleen 
contained  thick  pus  of  a  greenish  color, — an  unusual  occurrence  in  cases 
of  actinomycosis, — but  no  fungi.  The  spleen  was  the  seat  of  large  and 
numerous  minute  abscesses,  and  the  liver  and  kidneys  also  contained  small 
abscesses,  and  in  all  of  them  actinomyces  were  found.  Israel  claims  that 
this  case  affords  a  good  illustration  of  his  view  that  the  actinomyces, 
as  regards  its  effect  on  the  tissues,  occupies  a  position  half-way  between 
the  bacillus  of  tuberculosis,  which  produces  only  granulation-tissue,  and 
the  pus-microbes,  which  produce  pus.  It  was  impossible  in  this  case,  as 
in  so  many  others  in  which  multiple  deposits  have  been  found,  to  locate 
with  accuracy  the  primary  seat  of  infection.  The  teeth  were  perfect  and 
the  whole  digestive  tract  showed  no  evidence  of  disease.  Metastasis  in 
actinomycosis  takes  place  in  the  same  manner  as  in  pygemia  and  malig- 
nant tumors.  At  the  primary  seat  of  infection  the  fungus  or  its  spores  gain 
entrance  through  a  defective  vein-wall  into  the  general  circulation,  and,  at 
the  point  of  arrest  in  a  distant  capillary  vessel,  establish  an  independent 
centre  of  infection,  with  all  the  pathological  attributes  of  the  primary  infec- 
tion. General  infection  is  of  rare  occurrence  in  actinomycosis,  as  this 
disease  is  noted  for  its  tendency  to  extend  locally,  where  it  often  results 
in  extensive  regional  dissemination  and  destruction  of  tissue.  Actinomy- 
cosis resembles,  in  its  clinical  behavior,  very  closely  the  malignant  tumors, 
in  that  it  will  invade  every  tissue  with  which  it  comes  in  contact,  irre- 
spective of  its  anatomical  structure.  Primary  localization  is  very  apt 
to  occur  in  the  connective  tissue,  and  in  preference  it  extends  along  this 
structure;  but  periosteum,  bone,  muscles,  tendons,  cartilage, — in  fact,  all 
of  the  tissues  of  the  body, — succumb  to  the  fungus  as  quickly  as  they  be- 
come infected. 

In  actinomycosis  of  the  jaws  and  the  vertebrse  we  often  find  extensive 
destruction  of  bone,  with  large  abscesses  communicating  with  the  primary 
lesion.  Before  suppuration  takes  place  the  actinomycotic  swelling  is  quite 
firm  on  pressure,  and,  if  the  disease  extend  rapidly,  it  is  surrounded  by  a 
diffuse  cedema.  Pain  and  tenderness  are  usually  never  severe,  and  often 
almost  wanting.  Eedness  appears  as  soon  as  the  infection  has  extended 
to  the  skin.  Suppuration  usually  develops  in  consequence  of  direct  infec- 
tion with  pus-microbes  through  some  minute  surface  defect  in  the  swell- 


SYMPTOMS   AND    DIAGNOSIS.  641 

ing.  As  soon  as  suppuration  sets  in,  the  swelling  not  only  increases 
rapidly  in  size,  but  regional  diffusion  is  hastened  by  the  breaking  down 
of  the  granulation-tissue  that  before  held  the  fungi  fixed  in  their  re- 
spective localities.  The  same  tendency  to  migration  of  an  actinomycotic 
abscess  is  observed  as  in  tubercular  abscess.  The  characteristic  feature 
of  actinomycotic  pus  is  the  presence  of  minute,  macroscopical,  yellowish 
granules;  the  actinomyces,  on  careful  inspection,  can  almost  always  be 
discovered.  If  these  granules  are  placed  under  the  microscope  their  char- 
acteristic structure  will  at  once  become  apparent. 

The  differentiation  between  actinomycosis  and  syphilitic  gummata 
requires  the  greatest  care,  and  as  both  affections  are  benefited  by  the  ad- 
ministration of  potassic  iodide  the  therapeutic  effect  of  this  drug  does  not 
serve  as  a  diagnostic  criterion.  Evidences  of  tertiary  syphilis  in  other 
parts  of  the  body  must  be  looked  for  and  taken  into  careful  consideration 
in  formulating  a  diagnosis. 

In  cases  of  actinomycosis  of  any  of  the  internal  organs,  attended  by 
suppuration  and  discharge  of  pus  through  some  one  of  the  outlets  of  the 
body,  the  diagnosis  will  usually  depend  almost  exclusively  upon  the  de- 
tection of  the  fungus  in  the  discharges.  Microscopical  examination  of 
the  sputum  and  fgecal  discharges,  in  cases  of  suspected  actinomycosis  of 
the  lungs  or  the  intestines,  is  the  only  positive  means  of  making  a  differ- 
ential diagnosis  between  these  affections  and  pulmonary  and  intestinal 
tuberculosis.  Actinomycosis  of  the  skin,  mouth,  tongue,  and  jaws  might 
be  mistaken  for  sarcoma,  carcinoma,  tuberculosis,  and  syphilis.  As,  with 
the  exception  of  carcinoma,  all  of  these  affections  present  under  the 
microscope  an  histological  structure  that  it  would  be  often  difficult  to 
identify  microscopically,  the  differential  diagnosis  by  means  of  the  micro- 
scope must  rest  on  the  detection  of  the  ray-fungus  imbedded  in  the 
granulation-tissue.  Sarcoma  does  not  suppurate  or  break  down  as  early 
as  the  actinomycotic  or  tubercular  swelling.  Carcinoma  primarily  starts 
in  the  epiblast  or  hypoblast,  and,  even  during  the  earliest  period  of  the 
growth,  there  is  no  difficulty  in  demonstrating  an  intimate  relationship 
between  the  skin  or  mucous  membrane  and  the  tumor  encroaching  upon 
the  mesoblast.  In  actinomycosis  tissue-proliferation  takes  place  around 
each  fungus  in  the  mesoblast,  and  the  skin  or  mucous  membrane  is  in- 
fected and  destroyed  from  within  outward.  In  tuberculosis  regional  in- 
fection almost  always  occurs  through  the  medium  of  the  lymphatic  vessels 
and  glands,  while  these  structures  are  seldom  or  never  invaded  in  actino- 
mycosis. In  the  absence  of  microscopical  proof  of  the  nature  of  the  lesion, 
it  may  become  necessary  to  resort  to  a  therapeutic  test  in  differentiating 
between  syphilis  and  actinomycosis.  Large  doses  of  potassic  iodide,  ad- 
ministered four  times  a  day,  will  have  a  decided  effect  in  reducing  the 


■642  ,  PEINCIPLES    OF    SUEGEEY. 

size  of  a  gumma  in  the  course  of  two  or  three  weeks,  while  no  such  prompt 
result  will  be  obtained  if  the  lesion  is  of  an  actinomycotic  nature. 

PEOGNOSIS. 

Actinomycosis  is  a  more  dangerous  affection  than  tuberculosis.  While 
a  spontaneous  cure  not  infrequently  takes  place  in  the  latter,  we  have 
no  proof  that  actinomycosis  ever  terminates  in  such  a  satisfactory  manner 
without  the  surgeon's  aid.  Actinomycosis  of  the  internal  organs  proves 
fatal  almost  without  exception  on  account  of  the  inaccessibility  of  the 
disease  to  radical  surgical  treatment.  In  such  cases  numerous  fistulous 
openings  form,  discharging  profuse  quantities  of  pus,  and  the  patient 
dies  in  from  one  to  two  or  three  years  from  exhaustion  or  amyloid  de- 
generation of  the  internal  organs.  If  the  disease  is  located  in  external 
parts,  local  extension  often  takes  place  very  slowly  until  suppuration  sets 
in,  when  the  actinomycotic  abscess  migrates  from  place  to  place,  attacking 
all  the  tissues  that  come  in  its  way,  and  life  is  finally  destroyed  by  pyaemia, 
sepsis,  or  exhaustion.  The  prognosis  is  always  favorable  when  the  disease 
is  recognized  early,  and  when  it  is  located  in  parts  accessible  to  a  radical 
operation.  As  metastasis  is, of  rare  occurrence  in  actinomycosis,  complete 
removal  of  the  primary  focus  is  followed  by  a  permanent  cure.  The 
prognosis  of  actinomycosis  in  all  its  forms  and  in  all  parts  of  the  body 
has  been  made  much  more  favorable  since  it  has  been  shown  that  the 
potassie  iodide  possesses  decided  curative  properties  in  the  treatment  of 
this  disease. 

TEEATMENT. 

Thomassen  and  ISTocard  first  called  attention  to  the  value  of  the  in- 
ternal administration  of  potassie  iodide  in  the  treatment  of  actinomy- 
cosis in  animals.  Soon  after  the  publication  of  their  results  of  this  method 
of  treatment  Yan  Iterson  resorted  to  the  use  of  the  same  remedy  in 
the  treatment  of  the  same  disease  in  man  with  an  equally  satisfactory 
result.  Buzzi  and  Galli-Yalerio  have  also  reported  a  successful  case.  In 
this  case  the  disease  affected  the  whole  right  side  of  the  face,  from  the 
temple  to  the  clavicle.  Large  doses  of  the  drug  were  administred,  with 
the  effect  of  promptly  diminishing  the  profuse  suppuration,  followed  ulti- 
mately by  a  complete  cure  without  further  surgical  intervention.  Eydygier 
reports  two  cases  successfully  treated  by  parenchymatous  injections  of 
potassie  iodide.  A  case  of  actinomycosis  far  advanced  and  involving  the 
lower  Jaw,  the  left  side  of  the  face,  with  numerous  abscesses  about  the 
external  ear  and  in  the  parotid  and  submaxillary  regions,  came  recently 
under  my  care  in  the  clinic  of  Eush  Medical  College.  Owing  to  the  ex- 
tent of  the  disease,  a  radical  operation  was  out  of  question.    The  patient 


TREATMENT.  643 

was  a  man  35  years  of  age.  The  treatment  was  commenced  by  admin- 
istering 15  grains  of  the  potassic  iodide  four  times  a  day  and  the  sinuses 
were  washed  out  with  a  strong  solution  of  the  same  drug.  This  treatment 
was  continued  until  intoxication  was  produced  and  the  forehead  and  face 
were  thickly  studded  by  acne  pustules.  As  in  the  course  of  three  months 
no  decided  improvement  could  be  noted,  I  decided  to  continue  the  remedy 
in  the  same  doses  and  resorted,  besides,  to  its  use  by  cataphoresis.  A  15- 
per-cent.  solution  was  used  for  this  purpose  and  daily  sittings  for  fifteen 
minutes.  A  marked  improvement  was  apparent  in  less  than  two  weeks. 
This  combined  treatment  was  continued  for  nearly  four  months,  when  the 
;^atient  left  the  hospital  in  perfect  health.  No  indications  of  recurrence 
four  months  after  the  treatment  was  suspended.  This  case  has  satisfied 
me  that  cataphoresis  is  an  important  aid  in  the  administration  of  potassie 
iodide  in  the  treatment  of  actinomycosis.  It  appears  that  this  remedy 
deserves  a  thorough  trial  in  all  cases  prior  to  resorting  to  the  knife  and 
more  especially  in  cases  in  which  the  disease  is  so  extensive  as  to  preclude 
the  possibility  of  complete  removal  by  local  measures. 

Other  forms  of  general  treatment  in  actinomycoses  are  of  no  avail, 
and  all  local  measures,  short  of  complete  removal  of  the  infected  tissues, 
result  in  more  harm  than  good,  as  they  often  give  rise  to  secondary  in- 
fection with  pus-microbes,  which  always  aggravates  the  local  conditions 
and  hastens  a  fatal  termination.  In  cases  where  a  radical  operation  is 
out  of  question  on  account  of  the  extent  of  the  disease  or  the  importance 
of  organs  involved  in  the  process,  parenchymatous  injections  of  potassic 
iodide  or  a  2-per-cent.  solution  of  boric  acid,  a  1-to-lOOO  solution  of  cor- 
rosive sublimate,  or  a  l-to-1500  solution  of  nitrate  of  silver  might  be  tried; 
but,  on  the  whole,  such  injections  have  little  influence  in  arresting  the 
local  extension  of  the  disease.  Kottnitz  recommends  very  highly  cauteriza- 
tion with  solid  stick  of  nitrate  of  silver  in  actinomycosis  of  the  skin  and 
soft  parts  in  which  suppuration  and  formation  of  fistulous  tracts  have 
taken  place.  He  reports  four  cases  of  actinomycosis  of  the  head  and  neck 
treated  successfully  by  the  use  of  this  remedy.  Dr.  McGovern,  of  Wis- 
consin, also  reports  a  successful  case.  It  appears  that  this  caustic  pos- 
sesses a  specific  destructive  action  on  the  actinomycosis.  The  surgical 
treatment  of  actinomycosis,  before  suppuration  has  occurred,  consists  in 
the  excision  of  the  infected  tissues  in  all  cases  where  such  a  procedure  is 
practicable.  The  incision  should  be  carried  some  distance,  at  least  Va  to 
1  inch,  from  the  visible  granulations,  with  a  view  of  removing  not  only 
the  inflammatory  tissue,  but  also  the  minute  invisible  foci  in  its  imme- 
diate vicinity.  If,  after  the  excision,  suspicious  tissue  is  found  in  the 
wound,  this  should  be  removed  by  a  careful  dissection  with  forceps,  knife, 
and  scissors,  or  destroyed  by  using  the  actual  cautery.     Acids  and  other 


644  PEINCIPLES    OF    SURGEEY. 

chemical  caustics  should  not  be  relied  upon  in  destroying  the  infected 
tissues.  An  actinomycotic  abscess  should  be  treated  on  the  same  prin- 
ciples as  a  tubercular  abscess.  The  abscess-cavity  is  freely  exposed  by 
laying  open  the  fistulous  openings,  and  the  granulation-tissue  is  removed 
with  a  sharp  spoon.  Undermined  skin  is  cut  away  with  scissors.  If  the 
disease  has  extended  to  bone,  this  is  also  thoroughly  scraped,  and  it 
is  a  good  plan,  after  the  cavity  has  been  thoroughly  irrigated  and  dried, 
to  cauterize  the  whole  surface  with  the  actual  cautery.  Such  wounds 
should  not  be  sutured,  but  packed  with  iodoform  gauze,  in  order  to  keep 
the  infected  area  readily  accessible  to  inspection,  so  as  to  enable  the  sur- 
geon at  each  dressing  to  recognize  a  local  recurrence.  Should  this  occur, 
the  same  means  are  to  be  repeated  in  eliminating  the  infected  tissues. 
As  soon  as  the  wound  is  covered  with  healthy  granulations  it  may  be 
closed  by  secondary  suturing,  or,  if  this  cannot  be  done  on  account  of  too 
great  loss  of  skin-tissue,  the  defect  is  covered  with  large  skin-grafts  ac- 
cording to  Thiersch's  method.  Eepeated  scraping  operations  will  often 
succeed  in  finally  eradicating  the  disease,  provided  the  infected  parts  are 
accessible  to  vigorous  curetting  and  the  application  of  the  actual  cautery. 


CHAPTEK  XXV. 

Blastomycetic  Deematitis. 

Blastomycetic  dermatitis,  skin-blastomycosis,  pseudolupus  vulgaris, 
saccharomycosis  hominis,  and  pseudoepithelioma  with  hlastomycetes  are 
terms  which  have  been  used  to  signify  a  chronic  parasitic  inflammation 
of  the  skin:  an  affection  which  has  only  recently  been  recognized  and 
subjected  to  scientific  investigation.  Of  these  designations,  the  first  is 
best  calculated  to  indicate  the  anatomical  location,  the  parasitic  nature, 
and  pathological  character  of  the  disease.  This  affection  was  first  recog- 
nized in  the  lower  animals  (the  horse)  by  Tokishige,  a  Japanese  investi- 
gator, in  1893.  He  found  in  the  diseased  tissues  a  yeast-fungus,  an 
oidium,  the  etiological  significance  of  which  he  established  later.  The  fol- 
lowing year  appeared  the  account  of  the  disease  as  it  occurs  in  man,  based 
on  clinical  observations  and  careful  microscopical  and  bacteriological  in- 
vestigations by  Gilchrist  and  Stokes,  of  this  country,  and  Busse,  of  Ger- 
many. In  1899  Hektoen  could  find  only  four  well-authenticated  recorded 
cases,  and  among  these  was  one  case  which  came  under  my  own  treatment 
in  the  clinic  of  Eush  Medical  College  and  which,  at  the  time,  was  diagnosti- 
cated as  tiiberculosis  of  the  skin.  This  case  was  fully  described  by  Mr. 
H.  G.  Wells,  then  a  senior  student  and  assistant  in  the  surgical  clinic. 
Under  the  direction  of  Professor  Hektoen  he  made  a  careful  study  of  the 
specimen  in  the  Pathological  Laboratory,  which  resulted  in  correct  identi- 
fication of  the  disease  and  an  excellent  description  of  its  pathological  and 
bacteriological  aspects. 

"The  patient  was  brought  to  the  clinic  by  Dr.  J.  T.  Phillips,  of  West 
Union,  Iowa,  on  March  23,  1897.  Dr.  Phillips  had  observed  the  case  for 
over  a  year,  and  furnishes  the  following  history:  The  patient  is  a  well- 
nourished  man,  40  years  of  age,  a  native  of  Iowa,  farmer  by  occupation. 
He  presents  a  good  personal  and  family  history,  married,  has  five  healthy 
children,  none  of  whom  have  ever  had  any  similar  affection,  nor  has  any 
person  of  his  acquaintance.  A  thorough  physical  examination  shows  him 
to  be  free  from  any  pulmonary  or  glandular  involvement.  The  disease 
began  eleven  years  ago  as  a  small  pimple  on  the  back  of  the  first  phalanx 
of  the  left  little  finger.  This  pimple  became  an  ulcer,  which  gradually 
enlarged,  extending  up  over  the  knuckle  on  to  the  back  of  the  hand,  over 
Avhich  it  slowly  spread.  It  never  invaded  the  palm.  The  highest  it  ever 
reached  was  just  above  the  head  of  the  radius.  It  extended  from  the 
junction  of  the  palm  and  dorsum  of  the  hand  on  the  ulnar  side  of  the 

(645) 


646  PRINCIPLES    OF    SUKGEEY. 

base  of  the  thumb,  and  grew  down  to  the  second  phalanx  of  the  index 
finger,  to  the  middle  of  the  second  phalanx  of  the  second  finger,  just  be- 
yond the  first  phalanx  of  the  ring-finger,  and  never  extended  below  its 
starting-point  on  the  little  finger.  During  its  progress  the  older  portions 
of  the  lesion  would  sometimes  heal  up,  leaving  a  poor  substitute  for  skin, 
which  was  of  low-resisting  power,  for  it  would  rcpeatedy  become  reinvaded 
by  the  disease. 

"In  appearance  it  was  a  raised,  fungating  mass,  in  some  places  three- 
quarters  of  an  inch  above  the  normal  level  of  the  skin.     "When  washed 


.n 


Fig.  210. — A  Miliary  Abscess  in  the  Epithelium  of  the  Hand,  containing  in  its  Upper 
Half  a  Group  of  Three  Organisms.  X  220.  {After  Hektoen,  Journal  of  Experimental 
Medicine.) 

« 

it  was  of  a  dark,  cherry-red  color,  sprinkled  with  cheesy,  pinhead-sized 
masses.  After  being  left  for  a  time  the  surface  would  become  covered  with 
a  cru.st  of  pus,  scales,  and  debris,  which  was  readily  removed.  Secondary 
infection  frequently  occurred,  sometimes  producing  large-sized  abscesses. 
When  the  wet  dressings  that  had  been  applied  for  some  time  were  re- 
moved, the  growth  had  a  honey-combed  appearance  and  bled  very  easily. 
Every  ordinary  form  of  antiseptic  treatment,  hot  fomentations,  etc.,  were 
tried,  but  the  only  evident  effect  was  on  the  secondary  infection.     Early 


BLASTOMTCETIC    DEEMATITIS. 


647 


in  its  course  attempts  had  been  made  at  its  removal  by  caustics,  plasters, 
etc.,  without  result. 

"Pain  was  constant  in  the  hand,  often  especially  severe  at  night,  but 
the  patient  was  able  to  do  his  farm-work  and  felt  perfectly  well  otherwise 
during  all  this  time.  Although  there  were  abundant  opportunities  for  in- 
fection of  other  parts  of  the  body,  no  other  foci  ever  appeared,  and  the 
growth  was  solely  by  extension.  Dr.  Phillips  considered  it  a  case  of  skin 
tuberculosis,  and  Professor  Senn  agreed  to  the  diagnosis.  He  removed 
the  entire  area  involved,  covering  the  surface  by  a  plastic  operation,  with 


Fig.  211. 


-The  Three  Organisms  More  Highly  Magnified.     X  1500.     (After  Hektoen, 
Journal  of  Experimental  Medicine.) 


excellent  results.     Since  his  discharge  from  the  hospital  the  patient  has 
been  perfectly  well,  and  there  have  been  no  recurrences." 

At  that  time  there  was  very  little  known  concerning  blastomycosis 
of  the  skin,  and  the  macroscopical  appearances  resembled  tuberculosis  so 
closely  that  the  error  in  diagnosis  was  excusable,  so  much  more  so  as  the 
radical  operation,  notwithstanding  the  extent  of  the  disease,  proved  emi- 
nently satisfactory,  both  in  eliminating  th*e  disease  permanently  and  in 
yielding  an  ideal  functional  result.  The  skin  with  which  the  dorsum  of 
the  hand  was  covered  was  taken  from  the  anterior  surface  of  the  chest 
by  making  two  vertical  incisions,  elevating  the  flap  and  suturing  it  above  and 


648 


PEINCIPLES    OF    SUEGEKY. 


below  to  the  margins  of  the  dorsal  wound.  After  two  weeks  the  parts  were 
firmly  united  and  the  flap  was  detached.  Since  that  time  four  additional 
cases  of  blastomycetic  dermatitis  have  been  reported  by  physicians  of 
Chicago.  The  one  recorded  by  Anthony  and  Herzog  is  of  special  interest, 
as  they  showed  that  the  parasitic  disease  was  ingrafted  upon  a  syphilitic 
lesion,  and  the  one  by  Coates  demonstrating  that  it  is  clinically  and 
histologically  an  epithelioma.  (Fig.  210.)  The  one  reported  by  Hyde, 
Hektoen,  and  Bevan  proved  the  value  of  the  therapeutic  action  of  potassic 
iodide.  (Fig.  211.)  It  remains  an  open  question  whether  or  not  this 
case  was  complicated  by  syphilis. 

THE  FUNGUS  OF  BLASTOMYCETIC  DERMATITIS. 

Hektoen  has  made  a  special  study  of  the  morphology  of  this  strange 
and  as  yet  imperfectly  known  parasite.    The  size,  shape,  and  structure  of 


;   A-.'v/ 


Fig.  212.— An  Epithelial  Pearl  in  the  Centre  of  which  are  seen  Budding  Forms  Sur- 
rounded by  Granular  Debris.     {After  Coates.) 


the  organism  as  it  grows  upon  artificial  nutrient  media  vary  somewhat. 
Fresh  specimens  mounted  in  salt  solution,  from  the  culture  of  glycerin- 
agar,  show  a  highly-refractive  organism  with  a  doubly-contoured  envelope. 
The  fungus  resists  the  action  of  caustic  potash.  It  stains  readily  with  the 
common  aniline  solutions,  but  the  stain  is  rather  deep  and  in  many  cases 
too  diffuse,  and  the  clearest  pictures  are  obtained  by  a  rather  prolonged 
staining — fifteen  to  thirty  minutes — of  carefully-made  films  in  0.5-per- 
eent.  solution  of  methylene-blue  and  then  washing  well  with  water.     The 


THE    FUNGUS    OF    BLASTOMYCETIC    DERMATITIS.  649 

films  are  made  by  suspending  a  small  quantity  of  the  culture  in  a  drop  of 
physiological  salt  solution  or  of  distilled  water  and  drying. 

Large  bodies  are  not  as  constant  in  cultures  as  in  the  infected  tissues 
of  the  human  skin  or  infected  animals.  The  cell  membrane  is  separated 
from  the  cell-protoplasm  proper  by  a  clear  and  transparent  zone.  (Fig. 
212.) 

The  form  of  the  parasite  is  round  or  oval,  sometimes  polygonal  on 
account  of  mutual  pressure.  Budding  forms  are  very  frequent  and  occur 
in  all  stages  of  development.  The  process  of  budding  appears  to  begin 
with  the  formation  of  a  small  projection  of  the  endosporium,  which  pushes 
the  transparent  zone  and  outer  membrane  in  front  of  it.    Very  soon  these 


Pig.  213. — Vacuolated  and  Solid  Diffusely-Stained  Organisms  from  Glycerin-agar 
Culture.    (After  Hektoen.) 

layers  inclose  the  new  bud  fully  and  the  point  of  attachment  to  the 
mother-cell  may  be  either  flattened  or,  later,  drawn  out  into  a  slender 
pedicle.  In  well-developed  bodies  the  endosporium  is  vacuolated,  and  of 
varying  size,  and  deeply  stained,  sometimes  producing  appearances  that 
resemble  the  presence  of  a  nucleus,  but  this  is  not  constant.  With 
age  the  size  of  the  bodies  in  the  culture  gradually  increases,  and  the 
granules  are  then  either  crowded  to  one  side  or  become  arranged  as  a  rim 
around  the  vacuole  and  the  transparent  zone  becomes  indistinct  or  disap- 
pears altogether.  Large  bodies  with  huge  vacuoles  are  also  prone  to  form 
in  cultures  on  Loffler's  blood-serum.  (Fig.  213.)  By  means  of  stained 
microscopical  sections  of  the  stab  cultures  in  glucose-agar  and  gelatin 
it  is  readily  shown  that  the  peculiar  later  outgrowths  and  branchings 


650  PEINCIPLES    OF    SUEGEllY. 

observed  in  those  cultures  do  not  depend  upon  the  formation  of  mycelium, 
but  consist  of  budding  round  forms  exclusively.  The  organism  does  not 
attain  the  same  size  in  fluid  nutrient  media,  potato,  and  other  solid  sub- 
stances. Eepeated  budding  without  segmentation  may  give  rise  to  chains 
and  groups  of  various  lengths  and  size.    (Fig.  214.) 

In  some  cultures  a  distinct  mycelium  develops.  This  is  most  distinct 
in  Pasteur's  fluid  and  bouillon,  but  mycelioid  growths  may  occur  to  a  very 
slight  extent  in  all  media,  more  especially  plain  agar.    (Fig.  215.) 

The  formation  of  mycelium  is  due  apparently  to  a  gradual  elongation 
of  individual  organisms  of  the  smaller  type,  resulting  in  the  earlier  stages 
in  irregularly  cylindrical- shaped  bodies,  which  later  grow  out  into  either 
curved  or  fairly  straight,  rather  thick  rods  of  varying  lengths  or,  more 


f  4     ^ 


V 


Fig.  214.— Chains  of  the  Minute  Form.     {After  Eektoen.) 

rarely,  from  long  coiled  threads.  Buds  may  spring  from  any  part  of  the 
mycelium,  and  they  may  be  either  sessile  or  pedunculated.  The  cylindrical 
masses,  the  rods,  and  threads  vary  in  thickness,  the  average  being  about 
five  microns.  Cultures  on  agar-agar  are  frequently  characterized  by  the 
production  of  a  granular,  yellowish-brown,  at  times  also  reddish  pigment. 
Here  are  found  medium-sized  typical  bodies,  quite  a  few  oblong  and 
elongated,  narrow,  diffusely-stained  forms,  but  no  typical  mycelium,  and 
also  a  considerable  number  of  round  bodies  covered  and  surrounded  by 
yellow  or  yellowish-brown  pigment-granules  which  are  quite  uniform  in 
size.     (See  Fig.  215.) 

There  is  no  pigment  about  the  long  forms.     In  the  early  stages  of 
pigment  formation  the  granules  appear  in  the  immediate  vicinity  of  the 


INOCULATION    EXPEKIMENTS. 


651 


outer  capsule^  both  within  as  well  as  outside  of  it.  As  the  amount  of 
pigment  increases,  the  endosporium  disappears — a  fact  pointing  to  a  pig- 
mentary degeneration  of  these  bodies. 

The  author  has  been  placed  under  obligations  by  Professor  Hektoen 
for  the  free  use  of  his  classical  writings  on  blastomycosis  and  permission 
to  make  use  of  his  instructive  illustrations. 

INOCULATION    EXPERIMENTS. 

Certain  animals  are  susceptible  to  successful  inoculations  with  frag- 
ments of  blastomycetic  tissue  and  pure  cultures,  and  then  the  artificially- 
produced  disease  resembles  the  affection  as  it  occurs  in  man  clinically  and 


Fig.  215. — Development  of  Pigment-granules  Around  and  Upon  some  of  the  Larger  Cells 
in  Cultures  on  Plain  Agar.     Several  elongated  forms  are  present.     (After  Hektoen.) 


pathologically,  thus  furnishing  the  last  link  in  the  chain  of  evidences  proving 
the  etiological  relationship  of  the  fungus  to  the  disease. 

From  the  specimen  removed  from  my  case  Wells  inserted  a  piece  of 
tissue  subcutaneously  into  a  young  rabbit.  In  a  week  an  abscess  de- 
veloped, reaching  the  size  of  a  hickory-nut,  and  on  the  ninth  day  it  broke 
down,  forming  later  an  ulcer,  with  raised  margins,  from  which  could  be 
squeezed  a  whitish  pus.  A  second  rabbit  was  inoculated  with  this  pus,  and 
a  swelling  the  size  of  a  hazel-nut  made  its  appearance,  which  subsided 
in  a  short  time  and  did  not  reappear.  The  general  health  of  the  two 
animals  was  not  impaired,  and  at  the  end  of  three  months  the  one  first 
inoculated  was  killed.     No  lesions  could  be  found  in  any  of  the  viscera. 


652  PRINCIPLES    OF    SUEGERY. 

The  pus  from  the  abscess  was  carefully  and  repeatedly  examined,  stained, 
unstained,  and  treated  with  caustic  potash,  but  the  yeast-fungi  could  never 
be  found.  Cultures  from  the  abscess-contents  yielded  the  staphylococcus 
pyogenes  aureus.  It  is  evident  that  the  failures  in  these  two  experiments 
were  due  to  pus-infection  caused  either  by  the  pyogenic  microbes  con- 
tained in  the  blastomycotic  tissue  or  by  contamination  of  the  wound  during 
the  operation.  Eabbits  are  very  susceptible  to  pyogenic  infection  and  the 
diseased  tissue  was  eliminated  by  an  acute  suppurative  inflammation  be- 
fore the  fungus  had  sufficient  time  to  develop  to  reproduce  the  disease. 
Buschke  produced  in  Busse's  case,  experimentally,  follicular  acneiform 
nodules  through  inoculation,  which  became  necrotic  at  the  surface  in  five 
days,  and  contained  only  blastomycetes.  In  Busse's  case  the  disease  in- 
volved the  surface  of  the  left  tibia  and  appeared  as  a  subperiosteal  swell- 
ing, and  experiments  were  made  with  its  contents.  Inoculations  into  the 
marrow  of  the  tibia  in  rabbits  resulted  in  extension  of  the  disease  over 
the  entire  marrow  in  three  days.  Next  subperiosteal  inoculation  was  made 
in  a  dog  which  caused  rapidly-forming  swellings  containing  a  bloody  dis- 
charge. Inoculation  with  this  fluid  of  the  peritoneal  cavity  in  a  rabbit 
provoked  a  plastic  hsemorrhagic  peritonitis  and  enlargement  of  the  mesen- 
teric glands.  The  organism  was  found  in  the  inflammatory  products  in 
both  instances.  Staphylococci  and  other  microbes  were  generally  asso- 
ciated with  blastomycetes.  Subcutaneous  inoculations  in  mice  also  proved 
successful. 

Buschke  has  shown  that  the  duration  of  the  appearance  of  the 
specific  eruption  varies  from  6  days  to  8  to  10  weeks.  Hektoen  inoculated 
subcutaneously  with  1.5  cubic  centimetres  of  a  bouillon  culture.  A  small 
local  abscess  formed.  The  animal  died  in  ten  days.  The  abscess-cavity 
contained  a  few  cubic  centimetres  of  a  whitish-yellow  viscid  pus,  from 
which  the  blastomyces  grew  in  pure  culture.  The  internal  organs  were 
sterile. 

A  gray  mouse  died  five  days  after  receiving  1  cubic  centimetre  of  a 
bouillon  culture  subcutaneously.  The  abscess  which  had  formed  contained 
the  organism  in  pure  culture,  while  the  internal  organs  were  normal.  A 
medium-sized  rabbit  died  48  hours  after  subcutaneous  inoculation  of  2.5 
cubic  centimetres  of  a  bouillon  culture.  Cultures  from  the  internal  organs 
remained  sterile.  There  was  extensive  coccidiosis  of  the  liver.  There  were 
numerous  minute  foci  in  the  lungs  composed  of  epithelioid  and  giant  cells, 
as  well  as  leucocytes  with  considerable  nuclear  degeneration.  In  some 
of  the  giant  cells  were  circular  bodies  resembling  the  organism  injected, 
as  well  as  small,  round  bodies  that  stained  rather  profusely  with  methylene- 
blue,  presenting  a  faint  peripheral  transparent  zone. 

A  gray  mouse  was  inoculated  subcutaneously  with  1  cubic  centimetre 


PATHOLOGICAL   ANATOMY   AND   HISTOLOGY.  653 

of  a  bouilloii  culture.  It  died  in  five  days.  The  small  abscess  contained 
the  organisms,  as  well  as  staphylococcus  albus;  the  latter  organism  was 
present  in  all  the  internal  organs. 

In  two  rabbits  injections  into  the  anterior  chamber  of  the  eye  proved 
successful.  Two  intraperitoneal  injections,  one  in  a  guinea-pig  and  the 
other  in  a  white  rat,  reproduced  the  disease. 

A  large  black  rabbit  received  into  the  circulation  4  cubic  centimetres 
of  a  bouillon  suspension  of  a  culture  on  beer-wort  agar.  It  died  during 
the  following  night.  The  lungs  were  oedematous,  the  thymus  ecchymotic; 
the  liver  swollen,  soft,  and  mottled;  the  spleen  and  kidneys  appeared  nor- 
mal. Smears  from  the  various  organs  show  numerous,  clear,  round  bodies, 
not  destroyed  by  KOH;  they  are  most  numerous  in  the  smears  obtained 
from  the  lungs  and  kidneys. 

Inoculation  from  the  various  organs  on  glycerin-agar  yielded  numerous 
colonies  of  blastomyces,  most  numerous  from  the  tubules  of  the  kidneys. 
In  his  last  experiment  he  injected  8  cubic  centimetres  of  a  bouillon  culture 
into  the  jugular  vein  of  a  small  dog,  which  died  26  days  later.  The 
autopsy  and  microscopical  examination  showed  minute  foci  of  granula- 
tion-tissue throughout  the  lungs  and  softened  cellular  masses,  with  yel- 
lowish contents,  in  the  medullary  pyramids  of  the  kidneys.  The  blasto- 
mycetes  were  recovered  in  pure  growth  and  in  large  numbers  from  the 
lungs  and  the  kidneys.  The  experiments  noted  above,  more  especially  those 
of  Hektoen,  show  conclusively  that  dogs,  mice,  rats,  rabbits,  and  guinea- 
pigs  are  susceptible  to  blastomycetic  infection.  There  is  reason  to  believe 
that  in  some  of  the  animals  in  which  death  ensued  shortly  after  the  inocu- 
lation the  fatal  result  was  due  to  acute  sepsis  caused  by  pyogenic  infection. 

PATHOLOGICAL   ANATOMY   AND   HISTOLOGY. 

The  clinical  and  pathological  aspects  of  blastomycetic  dermatitis  have 
much  in  common  with  tuberculosis  and  epithelioma,  and  on  this  account 
the  differential  diagnosis  between  these  affections  even  at  the  present 
time  and  with  the  aid  of  modern  diagnostic  resources  is  not  always  easy. 
The  primary  efflorescences  resemble  acneoid  infiltration  at  the  apex  of 
which  necrosis  takes  place.  In  this  manner  crater-like  ulcers  form,  which 
increase  in  width  and  extent  to  the  tela  subcutanea,  and  the  ulcers  later 
enlarge  by  confiuence  with  sharp,  zig-zag,  more  or  less  undermined  and 
infiltrated  margins.  The  margins  are  livid  and  painful,  with  less  pain 
outside  of  the  limits  of  the  zone  of  infiltration.  The  discharge  from  the 
ulcerated  surface  is  viscid,  transparent,  sometimes  of  a  grayish  color,  some- 
times reddish  brown,  mixed  with  the  detritus  of  necrosed  tissue.  Some- 
times the  small  ulcers  heal  in  a  few  weeks.  The  new  ulcers  form  ap- 
parently in  connection  with  the  hair-follicles,  sometimes  independently 


654 


PRINCIPLES    OF    SURGERY. 


of  these,  but  in  connection  with  or  proximity  to  existing  ulcers.  Analo- 
gous changes  in  the  skin  take  place  by  perforation  of  subcutaneous  foci. 
The  disease  is  essentially  a  dermatitis  which  develops  usually  in  connec- 


^  .»~/ * 


o 


--^0 


Fig.    216.— Giant   Cell   showing   Budding   Vacuolated   Organism. 

tion  with  the  cutaneous  appendages,  and  gives  rise  to  ulcers  variable  in 
size,  which  remain  superficial  and  are  paved  with  a  layer  of  flabby,  oedema- 
tous  granulations.  The  blastomycetes  are  found  within  and  between  the 
cells,  their  favorite  location  being  in  the  giant  cells.    The  most  conspicuous 


Fig.  217.— Giant  Cells  containing  Organisms  in  Different  Stages  of  Development. 

change  is  the  marked  hyperplasia  of  the  epithelial  layer  of  the  skin.  Like 
in  an  epithelioma,  columns  of  epithelium  are  seen  growing  into  the  corium 
to  a  depth  of  about  four  millimetres,  uniting  masses  of  epithelial  cells 


PATHOLOGICAL    ANATOMY    AND    HISTOLOGY. 


655 


below  the  membrana  propria  to  each  other  and  to  the  thickened,  super- 
ficial, epithelial  stratum.  All  of  the  appendages  of  the  skin  are  destroyed. 
The  papillse  are  obscured  by  the  epithelial  infiltration.  In  serial  sections 
the  papillae  are  in  many  instances  seen  like  long,  finger-like  columns,  often 


Fig.  218. — Giant  Cell  stiowing  Organisms  Apparently  in  Sporulation-stage. 

bending  and  running  at  right  angles  to  the  surface.  (Fig.  219.)  The 
primary  minute  abscesses  are  surrounded  by  epithelial  cells  and  usually 
contain  giant  cells  and  the  fungi.  (Fig.  220.)  In  the  central  part  of  the 
larger  epithelial  columns  the  nuclei  and  the  chromatic-threads  are  indis- 
tinct, caused  by  degeneration  resulting  from  separation  by  a  small  space 


Fig.  219. — Section  showing  Epithelial  Proliferation.     Two  small  abscesses  in  an 
epithelial  peg  at  left  of  field.     {After  Herzog.) 

from  the  cell-protoplasm.  Leucocytic  infiltration  is  marked  and  miliary 
abscesses  are  numerous  in  the  epithelial  masses.  When  the  embryonal 
cells  are  less  numerous  the  subcutaneous  connective  tissue  is  made  up 
of  oedematous  cells,  which  bear  a  strong  resemblance  to  myxomatous  tissue 


656 


PEINCIPLES    OF    SUEGEEY. 


and  containing  in  their  meslies  eosin-staining  granules.  In  contradis- 
tinction to  the  tubercle  nodule  the  masses  of  granulation-tissue  in  the 
blastomycetic  product  are  very  vascular.  The  giant  cells  constantly  found 
in  the  corium  and  so  numerous  in  the  deeper  portion  of  the  inflammatory 
product  are  identical  in  form,  size,  and  peripheral  radiate  arrangement 
of  the  nuclei  with  the  typical  giant  cell  of  a  Langhans  tubercle.  Vacuola- 
tion — to  a  greater  or  less  extent — is  an  almost  constant  feature.  The 
parasites  are  most  constantly  found  in  the  miliary  abscesses  and  in  the 
giant  cells. 


»>  IT.  e>..'jv-~>^^ji  ■  jX: ''^y  '%^-^^^^^^^  "^'Y-  '^'■/'-  t 

i5^s:7^\'='J^=>5rk;^:^^^^r^^ 

L^-  C\^^''2ji/^^^-\- •''.•;  •'.  » •'^^oiy^'^^Kl:  ''^ 

^^•^c*^^^:?^^*' '  ♦  '••***  ^'*l'  '."'.'» ''  • '  !^^v\^'-'f  ^^^ 

^■)t>(j:^ui. '■''.'.'.';  '/•"- :'.'  '.•'.*  -.'•■•V'Vo'.'vviy  - '-^  ^' 

-^-^^}^ll\\^'r':'://-y'-y\-- ■- *:'.'.' V ."'oy  fe?r^; 

SW-'i^'^'i'^.  ^f  ^V- ':  f .^V'i^Vftffi 

^^Sw-'^y ,•;  *jj*^a  X' .•-'.'  •'. ' .  '/V ', ."",'.  "•'^  j/^-  ^ 

^f*l^*'""*'V^ft^* '-'■""»  "°'''^*''"''''^ 

^^^ tk* '•' '•'•'* '•' '1''' '  •' ■'"' '  ' •'' '• ' •  vy Wv^' 

W^'^^^^'"^^^^^^^ 

?T^>>^^^i^^^5iA ''"' '  •*,i^U5^l^-^-^'^T^J^^' 

't^^^^^m 

Fig.  220. — Miliary  Abscess  of  Blastomycetic  Dermatitis  containing  Two  Giant  Cells  in  the 
Centre  and  Two  Organisms  in  the  Lower  Part  of  the  Minute  Cavity. 


DIAGNOSIS. 

For  the  general  practitioner  the  diagnosis  of  blastomycetic  dermatitis 
will  always  remain  difficult  and  often  impossible.  If  he  wants  to  be  sure 
he  must  call  into  consultation  a  competent  microscopist.  All  we  can  ex- 
pect of  him  is  to  possess  enough  knowledge  of  the  clinical  features  and 
pathological  aspects  to  suspect  the  disease  when  he  sees  it,  and  rely  on  a 
positive  diagnosis  by  furnishing  an  expert  pieces  of  tissue  from  the  periph- 
ery of  the  inflammatory  product  for  microscopical  examination.  It  is  in 
the  newest  parts  of  the  inflammatory  product  that  the  organisms  and  giant 
cells  are  most  numerous.  The  practitioner  may  suspect  blastomycosis  in 
cases  in  which  an  isolated  territory  of  the  skin  becomes  the  seat  of  acne- 
like pustules  followed  by  minute  excavated  ulcers  which  by  confluence 
give  rise  to  progressive  extensive  destruction  of  the  skin.  A  tendency  to 
healing  of  the  small  ulcers  is  often  manifested,  but  new  eruptions  are  sure 
to  arise  in  the  neighborhood  of  the  minute,  imperfectly-developed  scars. 
It  is  as  yet  a  disputed  question  whether  blastomycetic  infection  can  take 
place  through  the  intact  skin;  there  is,  however,  very  little  doubt  concern- 
ing primary  infection  through  the  appendages  of  the  skin.     In  such  in- 


DIAGNOSIS.  657 

stances  the  presence  of  the  organisms  excites  a  folliculitis  which  results 
in  obstruction  of  the  outlet  of  the  gland  and  penetration  of  the  in- 
flamed gland-wall  by  the  blastomycetes.  The  occurrence  of  multiple 
acneoid  pustules  in  close  proximity  to  each  other,  followed  by  necrosis 
and  punctiform  excavated  ulcers,  should  always  call  attention  to  blasto- 
mycosis/ If  these  minute  ulcers  coalesce  and  progressive  ulceration 
leads  to  extensive  surface  destruction,  the  probability  of  the  ulcer  being 
blastomycetic  is  greatly  increased.  The  two  skin  affections  which  are 
most  likely  to  be  mistaken  for  blastomycosis  are  tuberculosis  and 
epithelioma.  In  tuberculosis  of  the  skin,  represented  by  lupus  vulgaris 
of  the  old  authors,  the  disease  does  not  so  often  start  from  multiple 
primary  points  of  infection  and  the  ulceration  is  more  likely  to  penetrate 
the  tissues  deeper  and  to  invade,  in  its  course,  tissues  irrespective  of  their 
anatomical  structure,  while  in  blastomycosis  the  destructive  process  begins 
in  and  is  largely  limited  to  the  skin,  the  ulcer  remaining  superficial. 
Epithelioma  exhibits  its  anatomical  points  of  predilection  to  a  greater 
extent  than  blastomycosis.  The  disease  begins  at  one  particular  point  and 
the  destructive  process  extends  from  one  common  centre  and  in  its  course 
invades  tissues  regardless  of  their  anatomical  structure  and  physiological 
properties.  The  induration  of  the  base  and  margins  of  the  ulcer  are  more 
marked  in  epithelioma  than  in  blastomycetic  dermatitis.  If  anything,  the 
pain  and  tenderness  in  blastomycosis  are  more  important  clinical  wit- 
nesses of  blastomycosis  than  epithelioma.  The  nature  of  the  discharge  is  also 
an  important  clinical  criterion  between  a  blastomycetic  and  an  epitheli- 
omatous  ulcer.  In  the  former  the  secretion  is  viscid,  in  the  latter  serous. 
In  an  epithelial  ulcer  under  pressure  a  solid  substance  can  be  squeezed  out, 
representing  the  degenerated  epithelial  cells  of  the  superficial  ulcerating 
carcinoma-nests.  Glandular  involvement,  as  a  rule,  is  absent  in  blasto- 
mycosis, while  in  epithelioma  it  appears  infallibly,  sooner  or  later,  in  the 
clinical  course  of  the  disease.  Finally,  in  epithelioma  very  often  the  clini- 
cal history  points  to  an  hereditary  aptitude  for  the  disease  while  no  such 
predisposition  can  be  assigned  to  blastomycosis.  Tertiary  syphilitic  ulcer- 
ations following  softening  and  breaking  down  of  gummata  bear  often  a 
close  resemblance  to  the  disease.  But  in  syphilitic  ulcerative  affections  of 
the  skin  the  clinical  history  will  often  come  to  our  aid  in  making  a  differ- 
ential diagnosis,  strengthened  by  the  discovery  of  syphilitic  lesions  in 
other  parts  of  the  body  and  the  existence  of  universal  hyperplasia  of  the 
lymphatic  glands.  Every  surgeon  is  well  aware  of  the  fact  that,  while  the 
clinical  course  of  blastomycetic  dermatitis  and  the  gross  pathological 
appearances  of  tissue-changes  are  well  calculated  to  arouse  suspicions 
concerning  the  nature  of  the  ulcerative  process,  the  final  diagnosis  must 
rest  on  microscopical  examinations  of  the  diseased  tissues.    The  discovery 


658  PEINOIPLES    OF    SUKGEEY. 

of  the  parasites  in  the  inflammatory  product  completes  the  diagnosis  as  far 
as  the  existence  of  blastomycosis  is  concerned,  but  does  not  exclude  the 
existence  of  complications,  such  as  tuberculosis  and  syphilis,  as  has  been 
shown  by  the  cases  reported  by  Hyde,  Hektoen,  and  Bevan,  and  Anthony 
and  Herzog.  Should  the  examination  of  tissue  removed  for  diagnostic 
purposes  leave  any  doubt  as  to  the  nature  of  the  ulcer,  the  last  and 
most  reliable  diagnostic  resource  must  be  resorted  to,  namely:  inoculation 
experiments.  These  will  yield  positive  results  in  blastomycosis  and  tuber- 
culosis and  negative  results  in  syphilis  and  epithelioma.  In  the  former 
instance  a  final  differential  diagnosis  will  be  made  by  a  bacteriological  exam- 
ination of  the  tissues  of  the  diseases  artificially  produced. 

PEOGNOSIS. 

Blastomycetic  dermatitis  manifests  no  tendencies  to  permanent  heal- 
ing of  the  ulcer.  Attempts  in  this  direction  are  constantly  followed  by 
local  aggravated  relapses.  The  intrinsic  tendency  of  the  disease  is  to 
progressive  extension.  During  the  early  stages  of  the  disease  it  is  amen- 
able to  successful  treatment  by  any  methods  which  destroy  its  essential 
parasitic  cause.  After  the  disease  has  become  extensive  and  in  neglected 
cases  the  danger  to  life  arises  from  metastatic  processes  involving  inter- 
nal organs,  as  has  been  shown  by  Busse's  case  and  the  interesting  ex- 
perimental work  of  Professor  Hektoen. 

TEEATMENT. 

Blastomycetic  dermatitis  is  amenable  to  early  efficient  surgical  treat- 
ment. In  the  absence  of  metastatic  processes  in  important  internal  organs 
the  disease  yields  to  any  method  of  treatment  which  insures  complete 
removal  or  destruction  of  the  infected  tissues.  The  surest  way  to  accom- 
l^lish  this  is  by  a  clean  and  complete  excision.  As  the  disease  is  always 
superficial,  this  can  be  accomplished  with  safety  and  precision.  If  the  dis- 
ease is  limited,  the  resulting  wound  can  be  closed  by  suturing;  if  more 
extensive,  it  is  paved  with  Thiersch's  skin-grafts,  and  in  large  defects  it 
becomes  necessary  to  resort  at  once  to  a  plastic  operation,  which  yielded 
such  a  satisfactory  result  in  the  author's  case.  In  cases  in  which  the  diag- 
nosis remains  doubtful  and  in  instances  in  which  a  radical  operation  is 
contraindicated,  either  on  account  of  the  extent  of  the  disease  or  the 
existence  of  metastatic  foci,  the  administration  of  potassic  iodide  deserves 
a  fair  and  extended  trial.  The  dose  administered  internally  should  be 
gradually  increased  from  1  to  4  or  6  grammes  four  times  a  day.  The 
author  strongly  recommends,  in  connection  with  gradually-increasing 
doses  administered  internally,  the  local  endermic  use  of  a  15-per-cent. 
solution  of  the  same  drug  by  cataphoresis. 


CHAPTEE  XXVI. 


Antheax. 


Synonyms.  — ■  Contagious  carbuncle;  charbon;  Milzbrand;  malignant 
pustule;  wool-sorters'  disease.  The  mycology  of  anthrax  is  better  under- 
stood than  that  of  any  other  microbic  disease.  The  bacillus  of  anthrax 
is  the  largest  of  the  known  pathogenic  microbes,  and  ever  since  it  was 
discovered  it  has  been  a  favorite  subject  of  investigation  in  every  labora- 
tory and  by  every  bacteriologist. 

HISTOEY. 

As  a  disease  among  animals,  anthrax  has  been  known  since  the 
earliest  records  of  history.  The  contagiousness  of  this  disease  has  been 
recognized  since  the  beginnning  of  the  eighteenth  century.  During  the 
first  part  of  the  present  century  it  was  described  as  a  blood  disease. 
Heusinger,  in  his  classical  work,  "Die  Milzbrand  Krankheiten  der  Thiere 
und  des  Menschen"  (Erlangen,  1850),  declared  anthrax  to  be  a  malarial 
neurosis.  In  the  year  1855  Pollender  published  his  discoveries,  which 
inaugurated  a  new  era  in  the  study  of  anthrax.  As  early  as  1849  he  dis- 
covered, in  the  blood  of  cattle  suffering  from  anthrax,  a  mass  of  innumer- 
able, fine,  rod-like  bodies  which  appeared  to  be  of  a  vegetable  nature  and 
resembled  vibriones.  Branell  found  the  same  rods  in  the  blood  of  men, 
horses,  and  sheep  which  had  died  of  anthrax.  He  also  detected  the  same 
bodies  during  life  in  the  blood  of  the  diseased  animals.  Delafond  regarded 
this  parasite  as  a  variety  of  leptothrix.  In  1863  appeared  the  work  of 
Davaine,  wherein  he  pronounced  these  rods  to  be  bacteria,  and  later  he 
called  them  laderidia.  He  believed  them  to  be  the  essential  cause  of 
anthrax,  as  the  disease  could  not  be  found  in  the  blood  that  did  not  con- 
tain them.  Through  the  labors  of  Pasteur,  Koch,  ISTaageli,  Bollinger,  and 
others,  the  bacterium  found  so  const'antly  in  the  blood  and  tissues  of 
anthracic  animals  finally  found  a  permanent  place  as  the  bacillus  anthracis 
among  the  schizomycetes. 

The  first  reliable  and  positive  accounts  of  the  disease  in  man  we  owe 
to  Fournier,  Montfils,  Thomassin,  and  Chabert,  who  published  their  de- 
scription of  the  disease  between  the  years  1769  and  1780.  Fournier  first 
distinguished  the  spontaneous  and  the  communicated  carbuncle  of  man. 
The  primary  existence  of  anthrax  in  man  wa's  asserted  by  Bayle  in  1800 
and  by  Davy  la  Chevrie  in  1807. 

(659) 


660 


PKINCIPLES    OP    SUEGEEY. 


DESCEIPTION   OF  THE   BACILLUS   OF  ANTHEAX. 

Non-motile  rods,  5  to  10  micromillimetres  long  and  1  to  1.25  micro- 
millimetres  broad,  and  threads  made  up  of  rods  and  cocci. 

The  rods,  as  a  rule,  are  straight;  only  when  they  grow  to  a  consider- 
able length  and  meet  with  resistance  they  become  slightly  curved.  The 
rods  and  threads  are  round,  and,  with  their  threads  truncated  at  right 
angles,  appear  as  though  they  had  been  cut  off  obliquely.  The  interior, 
as  long  as  fission  does  not  proceed,  is  perfectly  homogeneous,  and  ab- 
sorbs aniline  dyes  very  readily  and  uniformly.  The  development  of  spores 
in  long,  undivided  threads,  as  we  find  them  in  fluid  culture-media,  takes 
place  at  regular  intervals,  where  we  find  them  as  bright,  oval  spots  that 
become  more  and  more  apparent,  marking  the  direction  of  the  rods.  Upon 
solid  culture-media  the  development  of  spores  is  preceded  by  transverse 


Fig.  221. — Anthrax  Bacilli:  Spore-formation  and  Spore-germination.  A,  from  the 
spleen  of  a  mouse  after  twenty-four  hours'  cultivation  in  aqueous  humor.  Spores  ar- 
ranged in  rods  like  a  string  of  pearls.  X  650.  B,  germination  of  spores.  X  650.  0,  the 
same,  greatly  magnified.     X  1650.     {Koch.) 

segmentation  of  the  rods.  The  cell-membrane  of  each  section  finally  be- 
comes the  membrane  of  the  spore,  each  pole  of  the  spore  presenting  a 
small  mass  of  protoplasm  that  can  be  stained. 

(a)  Staining.  —  Cover-glass  preparations  of  fluid  specimens  can  be 
stained  with  a  watery  solution  of  any  of  the  aniline  dyes.  They  can  be 
rapidly  stained  with  a  drop  of  fuchsin  or  gentian-violet,  but  more  satis- 
factorily by  floating  the  cover-glass  for  twenty-four  hours.  The  prepara- 
tions are  dried  and  mounted  in  Canada  balsam.  The  spores  are  not  stained 
by  the  ordinary  methods.  Tissue-sections  containing  bacilli  are  best 
stained  by  Gram's  method,  and  after-stained  with  eosin  or  picro-carminate 
of  ammonium.  By  double  staining  the  rods  are  seen  to  consist  of  a  hya- 
line sheath  with  protoplasmic  contents. 

(b)  Cultivation. — The  bacillus  of  anthrax  grows  luxuriantly  in  dif- 


DESCEIPTION"    OF    THE    BACILLUS    OF   ANTHEAX. 


661 


ferent  fluid  and  solid  nutrient  media.  Bouillon  and  aqueous  humor  of  the 
eye  furnish  an  excellent  soil,  but  for  inoculation  purposes  the  cultures  are 
now  generally  grown  upon  solid  nutrient  media. 

Gelatin. — If  a  nutrient  medium  containing  from  5  to  8  per  cent,  of 
gelatin  is  inoculated,  a  whitish  line  develops  in  the  track  of  the  needle- 
puncture,  and  from  it  fine  filaments  spread  out  on  the  sides. 

In  a  more  solid  nutrient  gelatin  the  growth  appears  only  as  a  thick, 
white  thread.  The  culture  liquefies  the  gelatin,  and  the  growth  subsides 
as  a  white,  flocculent  mass. 


Fig.  222.— stab-culture  of  Anthrax  Bacilli  in  Gelatin,  Grown  at  Room-temperature 
(16°  to  18°  C).     Four  days  old.     Natural  size.     (Baumgarten.) 


Plate  Cultures. — Cultures  upon  a  sloping  surface  of  solid  nutrient 
agar-agar  or  gelatin  form  a  viscous,  snow-white  'plaque. 

Without  access  of  air  the  culture  does  not  grow,  the  bacilli  being 
aerobic. 

Potato. — Inoculation  of  sterilized  potato  yields  a  very  characteristic 
growth.  The  deep  chamber  containing  the  potato  is  placed  in  the  incu- 
bator, and  in  about  thirty-six  or  forty-eight  hours  a  creamy,  very  faintly 
yellowish  layer  forms  over  the  inoculated  surface,  with,  usually,  a  peculiar 
translucent  edge.  On  removing  the  cover  of  the  damp  chamber,  a  strong, 
penetrating  odor  of  sour  milk  is  emitted. 


663  PRINCIPLES    OF    SURGERY. 

MULTIPLICATION    OF    ANTHRAX    BACILLI    IN    THE    LIVING    BODY 
AND   THE    SOIL. 

In  the  body  of  living  animals  the  bacilli  multiply  exclusively  by  seg- 
mentation, and  never  produce  spores.  Spores  are  produced  only  in  dead 
nutrient  media,  and  under  certain  conditions  only,  among  which  a  proper 
temperature  is  the  most  important  factor.  The  limits  of  the  temperature 
vary  between  13  to  18°  C.  and  43°  C;  at  a  temperature  of  less  than 
13°  C.  growth  of  the  rods  and  spore-production  no  longer  take  place. 
Pasteur's  assertion  that  bacilli  and  spores  in  the  cadavers  of  buried  ani- 
mals are  active  when  brought  to  the  surface*  by  earth-worms  is  improbable. 
The  disease,  according  to  Koch,  is  spread  among  animals  by  germinating 
spores  which  attach  themselves  to  plants  and  grass  in  swamps  and  along 
river-banks,  and  which,  when  taken  in  with  the  food,  become  the  cause  of 
intestinal  anthrax. 

Schrakamp  and  Friedrich  are  of  the  opinion  that  bacilli  can  multiply 
in  the  superficial  layer  of  the  soil,  while  Kitt  maintains  that  fructification 
of  the  bacilli  takes  place  in  the  manure  deposited  in  pastures. 

INOCULATION    EXPERIMENTS. 

In  order  to  cause  death  of  animals  by  inoculation  with  the  bacillus  of 
anthrax,  a  pure  culture  of  anthracic  blood  must  be  injected  into  the  sub- 
cutaneous tissue  or  into  the  circulation,  or  the  virus  may  be  transmitted 
by  inhalation  or  by  feeding.  Goats,  hedgehogs,  mice,  sparrows,  cows, 
horses,  guinea-pigs,  and  sheep  can  be  readily  infected.  Eats  are  less  sus- 
ceptible. Pigs,  dogs,  cats,  white  rats,  and  Algerian  sheep  are  immune. 
Frogs  and  fish  have  been  rendered  susceptible  to  anthracic  infection  by 
raising  the  temperature  of  the  water  in  which  they  lived.  Koch  produced 
the  disease  artificially  in  rabbits  and  mice  by  injecting  a  drop  of  anthracic 
blood,  with  the  result  of  producing  death  usually  within  twenty-four 
hours.  After  death  sections  taken  from  different  organs,  stained  in 
methyl-violet  with  carbonate  of  potash,  were  examined  under  the  micro- 
scope, and  the  bacillus  was  found  in  great  abundance  in  all  of  them. 
When  magnified  fifty  diameters  such  preparations  present,  at  the  first 
glance,  an  appearance  as  if  a  blue  coloring  material  had  been  injected 
into  the  vessels.  Each  intestinal  villus  is  permeated  by  an  exceedingly- 
delicate  blue  net-work;  in  the  mucous  membrane  of  the  stomach  all  the 
capillaries  surrounding  the  gastric  glands  are  stained  blue;  in  the  ciliary 
process  each  projection  is  injected,  and  a  spiral  vessel  stained  of  a  dark- 
blue  color  leads  from  thence  to  the  iris  and  breaks  up  into  a  fine,  blue 
net-work,  with  loops  directed  toward  the  edge  of  the  iris.  The  liver  and 
lungs  and  the  glandular  structures,  such  as  the  pancreas  and  salivary 


INOCULATIOiS;    EXPERIMENTS. 


663 


glands^  are  completely  permeated  by  the  same  blue^  vascular  net-work. 
Indeed,  there  is  no  organ  which  is  not  more  or  less  injected  with  the 
blue  mass.  It  is,  however^  very  striking  that  this  injection  is  only 
present  in  the  capillary  vessels.  All  the  larger  vessels,  even  the  arteries 
and  veins  of  an  intestinal  villus,  are  either  not  at  all  stained  or  have  but  a 
light-blue  streak  in  their  interior,  and  that  only  here  and  there.  When 
magnified  250  times  one  can  see  that  the  blue  capillary  net-work  is  com- 
posed of  numerous  delicate  rods,  and  when  a  power  of  700  diameters  is 
used  it  is  found  that  the  apparent  injection  is  nothing  more  or  less  than 
the  bacillus  anthracis,  stained  dark-blue,  and  present  in  incredible  num- 
bers in  the  whole  capillary  system. 


=^.   B 


Pig.  223. — Anthrax  Colony  upon  Gelatin.     A,  after  twenty-four  hours;    B,  after 
forty-eight  hours.     X  80.     (FUlgge.) 

■  In  the  other  vessels,  especially  in  the  larger  ones,  often  only  a  single 
bacillus  may  be  met  with  at  long  intervals,  or  they  may  be  quite  absent. 

The  distribution  of  the  bacillus  in  the  caj)illaries  is  not,  however, 
quite  uniform.  There  are  fewer  in  the  brain,  in  the  skin,  in  the  capillaries 
of  the  muscle,  and  in  the  tongue  than  elsewhere;  on  the  other  hand,  in 
the  liver,  lungs,  kidneys,  spleen,  intestines,  and  stomach  they  are  always 
present  in  enormous  numbers.  In  the  capillaries  themselves  the  bacilli 
accumulate  in  largest  numbers  at  the  point  most  distant  from  the  nearest 
afferent  artery  and  the  efferent  vein;  that  is,  at  points  where  the  blood- 
current  is  slowest.  Where  the  bacilli  are  present  in  greatest  abundance  it 
not  unfrequently  happens  that  the  capillaries  become  torn,  and  blood, 
with  the  contained  bacilli,  is  extravasated.     This  occurs  most  frequently 


664: 


PEINCIPLES    OF    SURGERY. 


in  the  glomeruli.  Many  of  these  burst,  and  the  bacilli  pass  into  the 
uriniferous  tubules.  In  mice  the  spleen  is  more  especially  the  seat  of  the 
bacilli;  then  come  the  lungs  and,  last  of  all,  the  kidneys.  Frisch  inocu- 
lated the  cornea  in  animals  and  produced  a  keratitis,  caused  by  the  bacilli, 
which  multiplied  with  great  rapidity,  local  dissemination  taking  place 
through  the  corneal  spaces. 


Fig.  224. — Intestinal  Villus  of  Anthracic  Rabbit.     The  bacilli  in  capillary  vessels 
alone  stained.     X  250.     (Koch.)^ 


INPECTION   IX   MAN. 

An  intact  skin  furnishes  ample  protection  against  infection  with 
bacilli  or  spores,  but  the  slightest  abrasion  may  become  the  necessary  in- 
fection-atrium for  either  method  of  infection.  Machnoff  rubbed  agar- 
agar  cultures  of  anthrax  bacilli  mixed  with  a  little  lanolin  into  the  shorn 
skin  of  rabbits  and  in  every  instance  the  animal  died  about  the  third  day 
of  acute  general  anthrax.  The  skin  showed  no  microscopical  lesions,  but 
bacilli  were  found  in  the  hair-follicles.  The  animals  in  which  the  same 
substance  was  simply  applied  to  the  skin  did  not  contract  the  disease. 
During  the  act  of  rubbing  the  microbes  are  forced  into  the  hair-follicles, 
from  which  they  enter  the  tissues  and  the  general  circulation.  Infection 
may  occur  through  a  healthy  mucous  membrane,  either  with  bacilli  or 
spores.  As  the  anthrax  bacillus  is  a  non-motile  parasite,  penetration  of 
the  epithelial  lining  can  only  occur  by  local  growth  of  the  bacillus. 
Spores  are  such  minute  structures  that  they  can  reach  the  circulation 


^  Copied    from    "Traumatic   Infective    Diseases,"    by   permission   of   the    New    Sydenham 
Society,  London. 


INFECTION"    IN    MAN.  _  665 

through  a  healthy  mucous  membrane  in  the  same  manner  and  by  means 
of  the  same  agencies  as  we  have  found  necessary  for  the  transportation  of 
other  minute  foreign  parasites  from  the  mucous  surface  into  the  circu- 
lation. Ollivier  reports  the  case  of  a  baby,  5  months  old,  supposed  to 
have  a  severe  bronchitis.  The  chest  yielded  all  the  physical  signs  of 
bronchitis,  but  in  addition  there  was  some  general  oedema  and  an  erythem- 
atous patch  upon  the  upper  left  chest.  After  death,  on  the  ninth  day, 
the  "pustules"  were  found  in  the  bronchi.  In  this  case  infection  was 
caused  by  the  entrance  of  bacilli  or  spores  through  the  bronchial  mucous 
membrane.  Petrov  reports  a  case  of  pulmonary  anthrax  which  resulted 
in  death  on  the  fifth  day.  At  the  autopsy  numerous  anthrax  bacilli  were 
found  in  the  lymphatics  of  the  kmgs.     Bouisson  reports  a  case  in  which 


7, 


\ 


Fig.  225. — BaciUus  Anthracis.     From  a  section  of  kidney  of  a  mouse.     (Gram's  method 
and  eosin.    Zeiss  V12  o.i.,  ocular  2.)     (.After  CrooJcshank.) 

infection  evidently  occurred  through  the  mucous  membrane  of  the  in- 
testinal canal.  During  life  the  diagnosis  made  was  intestinal  obstruction. 
The  autopsy  showed  great  congestion  of  the  intestines;  the  mesenteric 
glands  were  greatly  enlarged.  One  Ioojd  of  the  intestine  was  greatly  swollen, 
and  a  thrombus  twenty  centimetres  long  was  found  in  the  immediate 
neighborhood.  In  this  case  bacilli  were  found  in  the  blood.  Zorkendorfer 
records  another  case  of  |)rimary  intestinal  anthrax.  The  bacilli  were 
found  in  the  blood  and  organs,  but  they  were  most  numerous  in  the  in- 
testinal lesions.  A  third  case  came  under  the  personal  observation  of 
Krumbholz.  The  disease  was  marked  by  choleraic  symptoms.  Bacilli 
were  found  in  the  peritoneal  exudate  and  the  blood,  and  microscopical 
examination  showed  that  they  had  entered  from  the  intestinal  wall  into 


666  PEINCIPLES    OF    SUEGERY. 

the  peritoneal  cavity  through  the  lymphatics.  In  man  infection  fre- 
quently takes  place  through  a  small  wound  or  abrasion  in  persons  handling 
the  infected  products  of  anthracic  animals,  such  as  avooI,  hair,  and  hides. 
In  other  instances,  insects,  such  as  mosquitoes  and  flies,  that  have  fed  on 
the  blood  of  living  anthracic  animals  or  the  dead  tissues  of  animals  that 
died  of  the  disease,  may  become  disease-carriers.  The  sting  of  such  an 
infected  insect  may  communicate  the  disease  with  the  same  degree  of 
certainty  as  an  intentional  inoculation  with  a  drop  of  anthracic  blood  or  a 
minute  .quantity  of  a  pure  culture. 

INTENSIFICATION    OF    VIEUS. 

While  it  is  known  that  some  chemical  substances  exert  an  attenuating  ^ 
influence  on  the  virulence  of  the  anthrax  bacillus,  it  has  also  been  found 
that  an  attenuated  virus  will  again  become  more  virulent  by  adding  cer- 
tain substances.  It  must,  therefore,  be  taken  for  granted  that  the  chem- 
ical composition  in  which  the  bacillus  is  suspended  influences,  in  one  way 
or  the  other,  its  virulence.  It  has  been  found,  for  instance,  that  the  addi- 
tion of  a  minute  quantity  of  lactic  acid  to  a  fluid  containing  the  bacillus 
in  an  attenuated  form  greatly  intensifies  its  virulence  within  a  very  short 
time.  Thus,  Arloing,  Cornevin,  and  Thomas  found  that  the  pathogenic 
power  of  a  fluid  containing  these  bacilli,  to  which  ^/bqo  part  of  lactic  acid 
had  been  added,  and  the  mixture  allowed  to  stand  for  twenty-four  hours, 
was  increased  twofold;  if,  then,  a  little  water,  containing  a  very  easily 
fermentescible  sugar,  is  added  to  the  mixture,  and  another  twent3'-four 
hours  allowed  to  elapse,  the  virulence  attains  its  maximum,  and  frogs 
inoculated  with  this  virus  die  in  .from  twelve  to  fifteen  hours;  whereas, 
when  inoculated  with  ordinary  virus,  they  live  from  forty  to  fifty  hours. 
Kitt  has  repeated  and  confirmed  these  experiments. 

ATTENUATION    OF    VIEUS    AND    PEOPHYLACTIC    INOCULATIONS. 

By  cultivating  the  bacillus  of  anthrax  in  neutralized  bouillon  at  42° 
to  43°  C.  (107.6°  to  109.4°  F.)  for  about  twenty  days,  the  infecting  power 
is  weakened,  and  animals  inoculated  with  it  are  protected  against  the 
disease.  A  still  greater  degree  of  immunity  is  obtained  by  inoculating  a 
second  time  with  material  that  has  been  less  weakened.  Animals  thus 
treated  are  then  protected  against  the  most  virulent  form  of  anthrax,  but 
only  for  a  time.  A  temperature  of  55°  C.  (131°  F.),  or  treatment  with 
1-  to  5-per-cent.  solution  of  carbolic  acid,  deprives  the  bacilli  of  their  viru- 
lence. The  virulence  of  the  bacillus  is  also  altered  by  passing  it  through 
different  species  of  animals.  Woolbridge  secured  immunity  against  an- 
thrax in  animals  by  cultivating  the  bacillus  in  an  alkaline  solution  at  a 
temperature  of  37°  C.  (98.6°  F.)  for  two  days.    At  this  time  the  fluid  was 


ATTENUATION    OF   VIKUS    AND    PROPHYLACTIC    INOCULATIONS.  667 

filtered  and  a  small  quantity  of  the  filtrate  injected  into  the  subcutaneous 
tissue  of  rabbits;  these  rabbits  remained  well,  and  subsequently  resisted 
injection  of  most  virulent  anthracic  blood. 

Hankin,  under  the  guidance  of  Koch,  at  the  Hygienic  Institute  of 
Berlin,  isolated  an  albuminose  from  anthrax  cultures,  which,  when  in- 
jected into  rabbits  and  mice  in  small  quantities,  rendered  these  animals 
immune  against  the  most  virulent  cultures.  The  albuminose  was  pre- 
pared from  the  cultures  by  precipitation  with  absolute  alcohol;  the  pre- 
cipitate was  well  washed  in  this  liquid  to  free  it  from  toxins, — since  it  is 
known  that  all  such  substances  are  soluble  in  alcohol.  After  the  addi- 
tion of  alcohol  it  was  filtered  off  and  dried,  then  redissolved  and  filtered 
through  Chamberland's  filter.  Four  rabbits  were  inoculated  with  virulent 
anthrax  spores,  and  3  of  them  received  an  injection  of  albuminose  into 
the  ear-vein  at  the  same  time;  the  latter  recovered,  while  the  remaining 
animal  not  thus  protected  died,  in  about  forty-eight  hours,  of  anthrax. 
In  another  experiment  10  mice  were  each  injected  with  the  millionth  part 
of  their  body-weight  of  anthrax  albuminose  and  with  active  vaccine  at 
the  same  time.  Of  these,  3  died  after  108  to  116  hours;  the  others  re- 
covered. Three  others  had  only  the  two-millionth  part  of  their  body- 
weight  of  anthrax  albuminose  and  active  culture.  Two  of  them  survived. 
Four  control  mice  were  inoculated,  and  all  died  of  anthrax.  He  has  come 
to  the  conclusion  that  when  a  large  dose  of  albuminose  is  injected  into 
an  animal  the  entrance  of  anthrax  bacilli  into  the  system  is  aided,  and 
when  a  small  dose  is  administered  immunity  is  acquired  against  its  poison- 
ous properties,  protecting  the  animal  against  subsequent  inoculations  with 
active  cultures.  It  has  been  recently  shown,  by  the  experiments  of  Ogata ' 
and  Jasuhara,  that  when  the  bacillus  of  anthrax  is  cultivated  in  the  blood 
of  an  immune  animal,  its  pathogenic  power  is  modified  so  that  it  no  longer 
kills  susceptible  animals,  and  may  be  used  as  a  protective  vaccine-material. 
Prophylactic  inoculations  of  sheep  with  mitigated  virus  have  been  carried  on 
upon  an  extensive  scale  in  France  by  the  late  Pasteur  and  his  pupils,  and 
recent  statistics  bearing  upon  their  value  in  protecting  animals  against 
anthrax  have  shown  them  effective  in  preventing  the  spread  of  the  disease 
in  infected  districts. 

More  recent  bacteriological  investigations  have  shown  that  an  antag- 
onistic action  exists  between  the  bacillus  of  anthrax  and  other  pathogenic 
microbes,  notably  the  diplococcus  pneumonia,  the  streptococcus  of  erysip- 
elas, the  staphylococcus  pyogenes  aureus,  and  the  bacillus  prodigiosus. 
Experiments  have  shown  that  the  growth  of  anthrax  may  be  retarded  or 
destroyed  entirely,  according  to  the  quantity  of  the  antagonist  injected. 
This  discovery  will  result  in  additional  resources  in  effecting  immunity 
and  open  a  new  field  in  the  treatment  of  this  disease. 


668  PRINCIPLES    OF    SURGERY. 


CLINICAL    VARIETIES    OF   ANTHRAX. 


Primary  bronchial  and  pulmonary  anthrax,  caused  by  the  inhalation 
of  dust  containing  bacilli  or  spores,  and  primary  anthrax  of  the  intes- 
tines, caused  by  eating  anthracic  meat  or  by  drinking  water  infected  with 
spores,  are  diseases  that  are  occasionally  met  with  in  man;  but,  as  these 
affections  belong  to  the  physician  and  not  to  the  surgeon,  the  student 
should  consult  any  of  the  modern  text-books  on  the  practice  of  medicine 
to  become  familiar  with  their  symptomatology. 

Buchner  has  studied  experimentally  the  entrance  of  the  anthrax 
bacillus  through  the  intact  mucous  membrane  of  the  bronchial  tubes. 
"The  bacillus  and  spores  were  administered  by  inhalations,  in  the  shape  of 
dry  powder,  and  suspended  in  steam.  On  examining  the  bronchial  mucous 
membrane  at  different  stages,  under  the  microscope,  it  was  seen  that  the 
spores  were  transformed  in  a  very  short  time  into  bacilli,  and  that  the 
latter,  by  their  growth,  pushed  themselves  between  the  cells  and  into  the 
capillary  vessels.  It  was  observed  that,  the  greater  the  pulmonary  irrita- 
tion, the  more  the  passage  of  the  microbes  was  retarded.  The  entrance  of 
the  bacilli  from  the  surface  of  the  mucous  membrane  into  the  capillary 
vessels  was  seen  to  depend  on  an  active  process. 

Secondary  anthracic  bronchitis,  pneumonia,  and  enteritis  are  met  with 
in  almost  all  cases  of  localized  anthrax  followed  by  secondary  general  in- 
fection. Primary  intestinal  anthrax  in  man  was  studied  by  Wahl,  Eeck- 
linghausen,  Buhl,  Wagner,  Bollinger,  Leube,  and  Frankel,  and  all  of  these 
authors  succeeded  in  demonstrating  the  presence  of  the  essential  microbic 
cause  in  the  inflamed  mucous  membrane.  When  the  microbe  enters  the 
body  through  the  mucous  membrane  of  the  gastro-intestinal  canal  with 
the  food  or  drink,  it  gives  rise  to  a  primary  anthrax  of  the  intestinal  canal, 
that  again  may  become  general  by  metastatic  dissemination  through  the 
systemic  circulation.  Localization  upon  the  mucous  surface  first  takes 
place  upon  the  most  prominent  part  of  the  valvulge  conniventes  on  the 
mesenteric  side  of  the  bowel,  and  from  here  the  infection  spreads  over 
the  entire  surface.  Vierhoff  has  collected  41  cases  of  anthrax  intestinalis, 
the  total  number  found  reported  up  to  1885.  The  author  himself  observed 
3  cases  of  secondary  intestinal  anthrax  in  the  hospital  at  Eiga.  Cases 
of  secondary  intestinal  anthrax — that  is,  localization  of  the  bacillus  of 
anthrax  in  the  mucous  membrane  of  the  intestinal  canal  after  external 
infection — were  known  to  the  older  authors,  while  observations  of  pri- 
mary localization  in  the  digestive  tract  date  only  from  the  middle  of 
the  last  century.  As  soon  as  general  infection  has  taken  place,  the  dif- 
fusion throughout  the  capillary  system  is  the  same  as  has  been  described 
under  the  head  of  "Inoculation  Experiments."     The  forms  of  anthrax 


CLIlSriCAL   VAEIETIES    OF   ANTHEAX.  669 

that  concern  the  surgeon  most  are  those  which  result  from  infection  of 
the  external  surface  by  the  introduction  of  the  bacilli  or  spores  through 
a  small  wound,  abrasion,  or  the  sting  of  an  infected  insect.  The  favorite 
location  for  the  develoj^ment  and  growth  of  the  anthrax  bacillus  in  man 
and  beast  is  in  the  connective  tissue;  it  is,  therefore,  immaterial  in  what 
manner  the  microbe  reaches  this  tissue,  as  localization  here  marks  the 
beginning  of  the  disease.  The  clinical  forms  vary  according  to  the  localiza- 
tion of  the  disease,  its  extent,  and  the  intensity  of  the  infection.  Most 
all  authors  follow  Bollinger^s  classification,  according  to  which  all  cases 
are  brought  under  one  of  the  following  varieties:  1.  Anthrax  acutissimus, 
or  apoplediformis.    2.  Acutis.    3.  Suhacutis. 

The  primary  location  of  the  disease  is  in  accordance  with  the  manner 
in  which  infection  has  taken  place.  W.  Koch  states  that  in  animals  and 
man  the  bacillus  can  enter  the  organism  through  one  of  the  following 
routes:  (a)  through  the  skin;  (b)  gastro-intestinal  canal;  (c)  respiratory 
passages. 

Anthrax  of  the  External  Surface. — Infection  of  the  subepidermal  con- 
nective tissue  can  only  occur  through  a  defect  in  the  epidermis;  hence, 
every  anthrax  of  the  external  surface  corresponds  in  its  location  with  an 
infection-atrium,  through  which  the  essential  microbic  cause  has  entered 
the  connective  tissue.  The  bacillus  of  anthrax,  when  brought  in  contact 
with  living  tissue  susceptible  to  its  pathogenic  action,  causes  an  acute 
inflammation  characterized  by  grave  alterations  of  the  capillary  wall  and 
rapid  exudation.  The  microbe  first  multiplies  at  the  primary  point  of 
invasion,  and,  if  it  does  not  meet  with  sufficient  tissue-resistance,  it  enters 
the  blood-vessels  and  causes  general  infection,  which  always  proves  fatal. 
Infection  occurs  most  frequently  in  exposed  parts  of  the  body;  thus,  of  63 
cases  of  anthrax  in  man,  collected  by  Slessarewskji,  the  disease  showed 
itself  6  times  on  the  face,  21  times  on  the  neck,  and  36  times  in  other 
places.  Trousseau  relates  that  in  Paris  20  persons  were  attacked  with 
anthrax  in  ten  years,  and  in  all  of  them  the  source  of  infection  could  be 
traced  to  horse-hair  imported  from  South  America.  The  pathologico-ana- 
tomical  conditions  vary  according  to  the  primary  seat  of  invasion,  the 
structure  of  the  organ,  and  seat  of  the  disease.  The  first  tissue-changes 
are  observed  at  the  point  of  inoculation.  Prom  a  prognostic  and  patho- 
logical point  of  view  external  anthrax  can  be  divided  into  two  distinct 
varieties:   1.  Anthrax  pustule.    2.  Anthrax  oedema. 

1.  Anthrax  Pustule. — This  is  the  so-called  malignant  pustule.  It  is 
usually  met  with  in  parts  not  covered  by  clothing,  as  the  fingers,  hands, 
and  face.  The  only  case  of  anthrax  pustule  that  has  come  under  the 
observation  of  the  writer  occurred  in  the  palm  of  the  hand  in  the  person 
of  a  robust  butcher.    The  base  of  the  pustule  attained  the  size  of  a  silver 


670  PEINCIPLES    OF    SUEGEKY. 

dollar  and  was  very  hard.  The  surface  of  the  pustule  sloughed,  leaving 
a  granulating  surface,  which  healed  slowly  under  antiseptic  treatment. 
This  form  of  the  disease  is  determined  by  the  anatomical  structure  of 
the  part  affected,  which  must  be  dense  and  vascular.  The  pustule  begins 
as  a  small,  red  point  that  resembles  the  bite  of  a  flea,  in  the  middle  of 
which  a  small  vesicle  appears,  which,  at  first,  contains  a  transparent 
serum,  and,  later,  becomes  sanguineous.  The  patient  complains  of  an 
itching,  burning  sensation.  The  skin  around  the  centre  of  the  pustule  is 
at  first  slightly  raised  by  the  inflammatory  infiltration  underneath  it. 
Within  twenty-four  or  forty-eight  hours  the  size  of  the  infiltrated  area  is 
as  large  as  a  nickel,  and  the  infiamed  part  presents  all  the  evidences  of  a 
very  acute  circumscribed  inflammation.  The  swelling  is  now  painful, 
tender  on  pressure,  and  exceedingly  firm  to  the  touch.  The  centre,  pre- 
viously occupied  by  a  vesicle,  is  of  a  brownish-red  or  blackish-gray  color, 
and  presents  indications  of  approaching  gangrene.  The  epidermis  ex- 
foliates, exposing  a  necrosed  area  the  size  of  a  pea  to  a  silver  half-dollar. 
The  dead  tissue  remains  firmly  connected  with  the  surrounding  indurated 
parts,  until  it  becomes  gradually  detached  in  the  course  of  the  suppura- 
tive inflammation,  which  ensues  sooner  or  later.  After  separation  of  the 
slough,  spontaneous  healing  may  take  place,  always  leaving  a  depressed 
scar.  In  this  form  of  anthrax  general  infection  seldom  occurs,  as  the 
infection  remains  local,  the  early  and  abundant  inflammatory  exudation 
forming  an  impermeable  wall  around  the  infected  zone,  beyond  which  the 
bacilli  cannot  escape.  General  infection,  however,  in  such  cases  occa- 
sionally takes  place  where  a  vein  becomes  implicated  in  the  process,  and 
general  infection  is  not  prevented  by  the  formation  of  a  plastic  thrombus 
on  the  proximal  side  of  the  intravenous  culture.  The  acuteness  of  the 
inflammation,  and  probably,  also,  the  direct  necrotic  effect  of  the  toxins 
of  the  bacilli,  invariably  result  in  necrosis  of  the  central  portion  of  the 
pustule,  which  is  the  most  characteristic  pathological  and  clinical  feature 
of  this  form  of  anthrax. 

2.  Anthrax  (Edema. — This  form  of  anthrax  follows  infection,  if  the 
tissues  around  the  infection-atrium  are  freely  supplied  with  loose  con- 
nective tissue  and  the  blood-supply  to  the  part  is  scanty:  conditions  which 
are  present  about  the  eyelids,  neck,  and  forearm.  Anthrax  in  these 
localities  appears  as  a  flat  infiltration  without  well-defined  borders,  and 
with  little  or  no  discoloration  of  the  skin.  In  a  case  of  this  kind  that 
came  under  my  care  the  primary  infection  occurred  in  the  temporal  region 
above  the  external  ear.  The  patient  was  a  cattle-dealer  about  40  years 
of  age.  The  oedema  spread  very  ra]3idly,  and  with  the  local  extension  the 
septic  symptoms  increased  proportionately.  Death  at  the  end  of  the 
'  second  week  was  preceded  by   symptoms   indicative   of   internal   sepsis. 


PATHOLOGY   AND    MORBID   ANATOMY.  671 

From  the  infiltrated  tissues  a  rapidly-spreading  oedema  extends  in  all 
directions.  This  form  of  anthrax  is  attended  by  greater  danger  of  general 
infection  than  anthrax  pustule,  as  the  bacilli  are  less  effectually  walled 
in  by  the  inflammatory  product.  Vesication,  exfoliation  of  cuticle,  and 
gangrene  may  also  take  place,  and  in  milder  cases  a  spontaneous  cure  is 
possible.  As  long  as  the  infection  remains  local  general  symptoms  are 
absent,  but  as  soon  as  general  infection  has  occurred  they  point  to  progressive 
septicEemia. 

PATHOLOGY  AND   MOEBID   ANATOMY. 

If  the  tissues  of  a  primary  anthrax  of  the  external  surface  are  ex- 
amined under  the  microscope,  all  the  appearances  of  an  acute  non- 
suppurative inflammation  are  shown.  The  specific  effect  of  the  bacillus 
on  the  tissues  results  in  serious  alteration  of  the  capillary  vessels,  which 
gives  rise  to  an  abundant  inflammatory  exudation.  In  malignant  pustule, 
or  anthrax  pustule,  the  paravascular  and  connective-tissue  spaces  become 
completely  blocked  with  leucocytes  in  a  remarkably  short  time,  and  ne- 
crosis of  the  central  portion  of  the  inflammatory  product  is  a  constant 
result  of  the  acute  ischemia  and  the  speedy  coagulation-necrosis  thus 
produced.  Anthracic  inflammation  never  terminates  in  suppuration 
unless  secondary  infection  with  pus-microbes  takes  place.  The  local 
oedema  in  the  oedematous  variety,  at  the  point  of  infection,  is  caused  by 
vascular  disturbances  due  to  the  presence  of  the  bacilli  within  the  blood- 
vessels and  the  interstitial  inflammatory  exudation  caused  by  their  pres- 
ence. In  fatal  cases  the  necropsy  reveals  the  same  changes  in  different 
organs  as  Koch  has  described  in  his  experiments  on  rabbits.  The  capil- 
lary vessels  in  every  part  of  the  body  will  be  found  completely  or  partially 
blocked  with  bacilli,  but  the  number  of  microbes  is  always  greatest  in  the 
most  vascular  organs,  as  the  spleen,  liver,  and  kidneys. 

The  bacilli,  as  in  mice-septicffimia,  will  be  found  in  the  capillary  ves- 
sels arranged  in  the  direction  of  the  blood-current,  and  most  numerous 
where  the  flow  of  blood  is  most  impeded,  as  at  points  of  intersection. 
General  infection  always  takes  place  through  blood-vessels.  The  inter- 
nal organs  are  found  enlarged  and  exceedingly  vascular  from  engorge- 
ment caused  by  the  capillary  obstruction.  Minute  extravasations  are 
found  in  different  organs  where  the  bacilli  are  most  numerous,  resulting 
in  complete  destruction  of  the  capillary  wall  and  rhexis.  The  secondary 
intestinal  affection  most  frequently  assumes  the  form  of  inflammatory 
liEemorrhagic  infiltration,  more  seldom  that  of  hgemorrhagic  catarrh;  ulcer- 
ations the  size  of  a  split  pea  to  2  inches  in  diameter  are  frequently  pres- 
ent, the  remaining  portion  of  the  mucous  membrane  showing  well-marked 
evidences    of    acvite    inflammation,    great    vascularity,    and    infiltration. 


672 


PEINOIPLES    OF    SURGERY. 


Mesenteric  glands  are  swollen  and  contain  numerous  bacilli.  The  bron- 
chial and  intestinal  mucous  membranes  exhibit  all  the  appearances  of  recent 
inflammatory  changes,  great  vascularity,  slight  thickening,  and  here  and 
there  minute  extravasations.  In  some  cases  the  meninges  of  the  brain 
show  well-marked  lesions  that  account  for  the  cerebral  symptoms  during 
life.  Pathologists  have  often  failed  in  locating  the  immediate  cause  of 
death  in  fatal  cases  of  anthrax,  and  various  theories  have  been  advanced 
at  different  times  to  determine  this  point. 


Fig.  226.— Anthrax:    Section  from  Liver.     X  700.     (Flugge.) 

In  the  most  virulent  form,  the  anthrax  acutissimus,  Bollinger  be- 
lieves that  the  rapid  growth  of  the  bacillus  in  the  blood  brings  about  a 
sudden  diminution  of  oxygen  and  a  surplus  of  carbonic  acid,  and  that 
death  takes  place  by  a  slow  process  of  asjDhyxia.  Against  this  theory  it 
can  be  maintained  that,  in  the  blood  of  animals  that  have  died  of  the 
acutest  form  of  the  disease,  comparatively  few  bacilli  are  found;  and, 
further,  that  in  the  experiments  made  by  Nencki,  on  the  blood  of  rabbits 
that  had  died  of  this  form  of  anthrax,  it  was  found  as  capable  of  oxy- 
genation as  the  blood  of  healthy  animals.  The  theory  that  death  results 
from  purely  mechanical  causes  due  to  the  presence   of  bacilli  in  great 


PATHOLOGY   AND    MORBID    ANATOMY.  673 

abundance  in  the  blood-vessels  is  likewise  not  tenable,  because  no  such 
fatal  degree  of  obstruction  in  the  capillary  circulation  has  been  found  at 
the  post-mortem  examinations.  As  a  third  hypothesis,  Bollinger  advanced 
that  the  bacillus  may  generate  a  chemical  poison  that  may  cause  death  by 
intoxication.  In  reference  to  the  last-mentioned  cause,  Hoffa  calls  atten- 
tion to  the  following  three  possibilities: — • 

1.  The  bacilli  of  anthrax  are  in  themselves  poisonous,  and  the  in- 
crease in  their  number  increases  the  quantity  of  the  poison  in  the  same 
ratio.  Against  this  supposition  the  results  of  the  experiments  made  by 
Hoffa  himself  furnish  the  most  conclusive  proof.  Of  a  pure  culture  of 
anthrax  bacilli  he  injected  a  large  quantity  directly  into  the  jugular  veins 
of  rabbits.  The  animals  thus  infected  showed  no  symptoms  of  acute  in- 
toxication, but  died  in  the  same  manner  as  animals  infected  in  the  usual 
way. 

2.  The  bacilli  of  anthrax  produce  a  poison  capable  of  causing  fer- 
mentation in  the  blood;  this  poison  is  soluble  in  the  blood.  The  fact 
that  filtered  blood  of  animals  that  had  died  of  anthrax  did  not  produce 
toxic  symptoms  when  injected  into  healthy  animals  speaks  against  this 
argument. 

3.  The  bacillus  of  anthrax  separates  toxic  substances  from  complex 
combinations  in  the  organism.  This  last  explanation  appears,  from 
analogy  of  the  views  that  are  now  entertained  of  bacteria  and  toxins,  to 
be  the  most  plausible,  and  he  made  an  effort  to  produce  such  substances 
outside  of  the  animal  body,  upon  artificial  culture-media.  For  this  pur- 
pose he  cultivated  the  bacillus  with  the  greatest  precautions  upon  sterilized 
meat  kept  for  several  weeks  in  an  incubator  at  37°  C.  (98.6°  F.).  The 
chemical  product  thus  obtained  he  attenuated  according  to  the  methods 
advised  by  Stass-Otto,  Brieger,  and  after  the  more  recent  method  of 
Fischer. 

By  the  methods  of  Stass-Otto  and  Fischer  he  succeeded  in  producing 
a  substance  that  possessed  an  alkaline  reaction,  and  produced  toxic  effects 
in  animals.  A  strictly-pure  article  and  an  accurate  chemical  description 
of  it  could  not  be  obtained,  on  account  of  the  smallness  of  the  quantity 
produced.  The  substance  produced  by  Stass-Otto's  method  was  used  in 
experimenting  on  frogs,  mice,  guinea-pigs,  and  rabbits;  both  of  them  pro- 
duced symptoms  of  intoxication.  After  a  short  period  of  intoxication, 
with  increased  action  of  the  heart  and  accelerated  respiration,  the  animals 
became  somnolent;  respirations  deep,  slow,  and  irregular,  assisted  by  the 
action  of  all  accessory  muscles  of  respiration;  pupils  dilated,  temperature 
normal,  diarrhoea,  faeces  bloody;  speedy  death.  At  the  necropsy  the 
heart  was  found  contracted,  the  blood  was  of  a  dark  color,  and  ecchymosis 
of  the  pericardium  and  peritoneum  existed.     There  were  no  microorgan- 


674  PRINCIPLES    OF    SUEGEET. 

isms  in  the  blood.  The  pathological  conditions  described  here  are  an 
accurate  duplication  of  the  post-mortem  description  in  fatal  cases  of  an- 
thrax. The  same  author  succeeded  subsequently  in  isolating,  by  a  com- 
plicated process,  a  toxic  substance  from  the  bodies  of  anthracic  rabbits 
with  the  formula  CgHglSTg,  which  he  called  anthracin,  besides  a  small  quan- 
tity of  methyl-guanidin.  To  the  former  substance  he  attributes  the  toxic 
symptoms  in  cases  of  anthrax.  Injected  subcutaneously  in  rabbits,  it  pro- 
duced first  restlessness,  rapid  pulse,  and  accelerated  respiration,  followed 
by  somnolence,  deeper  and  slower  respiration,  diarrhoea,  asphyctic  symp- 
toms, convulsions,  and  death.  This  substance  is  closely  allied  to  hreatin, 
and  contains  23  per  cent,  of  nitrogen.  These  experiments  leave  but  little 
doubt  that  the  fatal  termination  in  cases  of  anthrax  is  caused  by  the  action 
of  toxic  substances  formed  in  the  body  in  consequence  of  the  action  of  the 
bacilli  upon  certain  as  yet  unknown  combinations  in  the  organism. 

DirFBEE]SrTIAL   DIAGNOSIS. 

Anthrax  must  be  distinguished  from  other  forms  of  acute  circum- 
scribed inflammation,  notably  from  furuncle  and  carbuncle.  A  furuncle 
is  conical  from  the  beginning,  and  the  summit  is  transformed  into  a  small 
slough.  A  carbuncle  is  nothing  more  nor  less  than  a  multiple  furuncle, 
and  is  produced  by  the  same  microbic  cause.  Anthrax  develops  from  a 
single  centre,  and  the  infiltration  proceeds  from  this  point  in  all  direc- 
tions. Necrosis  is  preceded  by  vesication,  and  the  black,  necrosed  tissue 
is  fully  exposed  after  exfoliation  of  the  epidermis.  The  oedematous  form 
of  anthrax  might  be  mistaken  for  erysipelas  or  acute  phlegmonous  inflam- 
mation. Anthrax  oedema  is  usually  not  attended  by  much  discoloration 
of  the  skin,  and  there  is  no  such  distinct  and  abrupt  line  of  limitation 
as  in  erysipelas.  Phlegmonous  inflammation,  when  advanced  to  the  ex- 
tent where  it  may  resemble  anthrax  oedema,  has  gone  on  to  the  stage  of 
suppuration.  The  differential  diagnosis  between  malignant  oedema  and 
anthrax  can  only  be  made  by  searching  for  the  primary  microbic  cause  by  the 
use  of  the  microscope.  A  positive  differential  diagnosis  between  suppurative 
lesions  and  anthrax  can  be  made  in  the  course  of  one  or  two  days  by 
inoculation  experiments.  If  a  rabbit  or  mouse  is  infected  with  a  drop  of 
anthracic  blood  or  serum  taken  from  the  centre  of  the  inflammatory- 
product,  death  from  anthrax  will  follow  within  two  days;  while  the  same 
amount  of  fluid  taken  from  a  suppurative  depot  will  produce  no  effect,  or, 
at  most,  only  a  circumscribed  abscess.  As  the  anthrax  bacillus  can  be 
readily  stained  and  identified  under  the  microscope,  a  positive  differential 
diagnosis  between  these  affections  can  always  be  made  by  the  use  of  the 
microscope. 


TEEATMENT.    .  675 


PEOGNOSIS. 


The  location  of  the  disease,  the  character  of  the  tissues  primarily 
affected,  and  the  general  condition  of  the  patient  greatly  influence  the 
prognosis  in  cases  of  anthrax.  The  prognosis  is  most  favorable  in  young, 
healthy  individuals  suffering  from  anthracic  pustule,  as  in  such  instances 
the  general  strength  of  the  patient  and  the  active  tissue  proliferation  at 
the  seat  of  infection  are  well  calculated  to  prevent  general  infection; 
while,  in  persons  debilitated  from  any  cause  affected  with  the  oedematous 
variety,  general  infection  is  very  liable  to  follow.  An  anthrax  oedema  of 
the  hand  or  arm  is  a  less  serious  condition  than  a  similar  affection  of  the 
face  or  neck.  As  a  general  rule,  it  may  be  stated  that,  the  firmer  and 
more  circumscribed  the  local  lesion,  the  more  favorable  the  prognosis,  and 
vice  versa,  the  more  extensive  the  area  of  infection  and  the  more  diffuse 
the  oedema,  the  greater  the  danger  to  life  from  general  infection.  The 
occurrence  of  general  infection  may  be  recognized  without  difficulty  by 
the  general  symptoms,  which  indicate  the  existence  of  progressive  septic 
infection.  The  bacillus  of  anthrax  multiplies  with  great  rapidity  after 
its  entrance  into  the  circulation,  and  the  anthracin,  which  produces  the 
septic  symptoms,  is  elaborated  in  amounts  proportionate  to  the  number 
of  bacilli  in  the  body.  Fever,  cough,  rapid  respiration,  feeble  and  rapid 
pulse,  diarrhoea,  and  delirium  are  some  of  the  symptoms  indicating  that 
the  disease  Jias  become  general.  All  hope  of  recovery  must  be  abandoned 
as  soon  as  general  infection  has  occurred;  death  from  progressive  infec- 
tion and  intoxication  will  be  certain  to  take  place,  in  spite  of  the  most 
heroic  local  and  general  treatment. 

TEEATMENT. 

The  surgical  treatment  of  anthrax  must  be  directed  toward  the 
elimination  or  neutralization  of  the  primary  microbic  cause.  As  within 
the  living  body  the  reproduction  of  the  primary  cause  takes  place  ex- 
clusively by  segmentation  of  the  bacilli,  any  germicidal  agents  that  in- 
hibit or  destroy  the  pathogenic  property  of  the  bacilli  will  be  found  useful 
in  the  local  treatment  of  anthrax.  It  has  been  found  experimentally  that 
a  5-per-cent.  solution  of  carbolic  acid  will  arrest  the  growth  of  anthrax: 
cultures,  and  clinical  experience  has  demonstrated  that  the  same  solution,, 
when  brought  in  contact  with  the  infected  tissues  by  parenchymatous  in- 
jections, has  a  decided  influence  in  arresting  further  extension  of  the 
infection. 

Lande  reports  3  cases  of  malignant  anthrax  saved  by  parenchymatous 
injections  of  carbolic  acid.  In  the  first  case,  a  man  aged  27,  the  upper 
lip  was  the  seat  of  the  disease;    in  the   second,   a  woman  aged   65,  the 


676  PRINCIPLES    OF    SURGEEY. 

anthrax  occupied  the  region  below  the  scapula.  Both  patients  were  very 
ill,  low  delirium  and  other  symptoms  of  toxaemia  being  present.  The 
injections  were  made  into  the  subcutaneous  tissue  around  the  pustule. 
The  strongest  solution  used  consisted  of  15  grammes  of  neutral  glycerin 
and  an  equal  part  of  distilled  water,  in  which  3  grammes  of  pure  carbolic 
acid  were  dissolved.  The  injections  were  made  at  five  points  around  the 
pustule,  and  represented  a  total  dose  of  50  centigrammes  of  the  acid.  The 
injections  caused  considerable  pain,  but  very  rapid  improvement  followed. 
The  solution  used  (10  per  cent.)  wa&  stronger  than  any  previously  employed 
for  the  same  purpose  by  Boeckel,  Raimbert,  and  others.  A  5-per-cent. 
solution  in  ordinary  cases  is  strong  enough,  but  in  grave  cases  the  10-per- 
cent, solution  must  be  used  until  improvement  takes  place,  which  should 
occur  within  forty-eight  hours.  Potiejenko  has  tried  the  parenchymatous 
injections  of  a  10-per-cent.  solution  of  carbolic  acid  in  four  exceedingly 
severe  cases  of  anthrax,  and  has  obtained  a  complete  cure  in  all  of  them. 
Three  or  four  syringefuls  of  the  solution  were  injected  into  the  swelling 
and  its  neighborhood  once  daily,  the  part  being  kept  covered  in  the  inter- 
val with  compresses  soaked  in  a  5-per-cent.  solution  of  the  same  antiseptic. 
Amoldow  speaks  very  highly  of  the  treatment  of  anthrax  by  parenchyma- 
tous injections  of  corrosive  sublimate  dissolved  in  a  5-per-cent.  solution  of 
carbolic  acid  in  the  proportion  of  2  grains  to  the  ounce.  The  object  of  the 
parenchymatous  injections  should  be  to  saturate,  as  far  as  possible,  all  of  the 
infected  tissues  with  the  antiseptic  for  the  purpose  of  destroying  the  bacilli, 
and,  at  the  same  time,  to  permeate  the  surrounding  healthy  tissue  for  some 
distance,  with  a  view  of  destroying  the  soil  for  the  growth  of  the  microbes 
in  advance  of  the  invasion.  The  surface  over  the  entire  infected  area 
should  be  rendered  thoroughly  aseptic,  in  order  to  prevent  secondary  in- 
iection  with  pus-microbes  through  the  needle-punctures.  The  punctures 
should  be  made  a  few  lines  from  the  border  of  infiltration,  but  always 
toward  the  centre  of  the  infected  district.  The  injection  is  made  gradu- 
ally as  the  needle  is  withdrawn,  so  as  to  saturate  the  tissues  for  some 
distance  along  the  entire  length  of  the  track  of  the  needle.  At  one  sitting 
from  four  to  twelve  injections  are  made,  according  to  the  size  of  the 
anthrax  and  the  urgency  of  the  symptoms.  A  compress  wrung  out  of  a 
1-to-lOOO  solution  of  corrosive  sublimate  should  be  kept  constantly  ap- 
plied. Application  of  an  ice-bag  over  the  antiseptic  compress  will  assist 
the  germicidal  agents  in  retarding  or  arresting  further  multiplication 
of  the  bacilli  in  the  tissues.  The  injections  should  be  repeated  every  six 
hours  until  the  disease  is  under  control,  or  until  it  is  deemed  unsafe,  from 
.  the  quantity  injected,  to  administer  more  carbolic  acid  for  fear  of  causing 
intoxication.  Excision  has  been  objected  to  on  the  ground  that  the  wound 
might  become  a  new  source  of  infection,  and  thus  leave  the  patient  in  a 


TEEATMENT.  .  677 

more  precarious  condition,  so  far  as  general  infection  is  concerned,  than 
before  the  operation;  but  such  is  not  the  case  if  the  area  of  infection  is 
limited  and  the  incisions  can  be  made  through  healthy  tissue.  The  fol- 
lowing case  affords  a  good  illustration  of  the  value  of  excision  of  anthrax 
in  well-selected  cases: — 

Kaloff,  of  St.  Petersburg,  in  making  experiments  with  anthrax  on 
animals,  accidently  infected  himself,  either  by  a  needle-puncture  or  by 
handling  the  organs  of  anthracic  animals.  The  local  infection  appeared 
on  the  outer  side  of  the  thumb  of  the  left  hand  as  a  small  vesicle,  which 
soon  disappeared,  but  gave  place  to  circumscribed  infiltration  on  the  sec- 
ond day.  This  inflammation  rapidly  extended,  and  was  surrounded  by 
hgemorrhagic  vesicles.  The  indurated  tissues  were  promptly  removed  by 
excision;  nevertheless,  on  the  next  day,  swelling  of  axillary  glands  on  the 
same  side,  fever,  great  prostration,  also  diarrhoea,  set  in.  The  skin  in 
the  axillary  region  and  side  of  chest  was  much  swollen  and,  at  different 
points,  bright  red,  at  others  bluish  red.  One  of  the  axillary  glands,  the 
size  of  a  hen's  egg,  and  glands  along  the  margins  of  the  pectoralis  major 
muscle  were  removed  and  the  field  of  operation  thoroughly  disinfected  with 
a  5-per-cent.  solution  of  carbolic  acid;  the  same  solution  was  also  thrown 
into  the  surrounding  tissues  with  an  hypodermic  syringe.  Cessation  of 
fever  and  rapid  healing  of  wound,  followed  by  recovery.  The  diagnosis 
was  confirmed  by  successful  cultivations  made  with  fragments  of  the  ex- 
cised tissue  in  bouillon  and  gelatin.  Excision  should  always  be  resorted 
to  in  cases  of  anthrax  pustule,  as  it  fulfills  the  etiological  indications  more 
promptly  and  thoroughly  than  any  other  treatment.  The  incisions  should 
be  made  outside  of  the  indurated  tissues,  and,  for  the  purpose  of  pre- 
venting traumatic  dissemination  of  the  disease,  the  surface,  after  thorough 
irrigation,  should  be  brushed  over  with  a  10-per-cent.  solution  of  carbolic 
acid  before  the  wound  is  sutured.  This  procedure  will  destroy  any  bacilli 
that  may  have  become  deposited  upon  the  surface  of  the  wound. 

In  the  case  just  cited  it  is  possible  that  lymphatic  infection — an  un- 
usual occurrence  in  anthrax — developed  in  consequence  of  the  entrance 
of  bacilli  into  the  open  lymphatic  vessels  on  the  surface  of  the  wound. 
Mliller  asserts  that  it  is  impossible  to  eliminate  the  disease  by  excision  of 
the  seat  of  inoculation.  In  guinea-pigs  amputation  of  the  limb  performed 
a  few  hours  after  the  foot  had  been  inoculated  failed  to  save  the  animal. 
He  recommends  the  following  treatment:  Immobilize  the  affected  part 
and  neighboring  joints  to  prevent  dissemination.  Elevate  the  limb. 
Apply  mercurial  ointment  and  give  alcohol  in  large  doses.  On  the  other 
hand,  Tillmanns  insists  that  anthrax  remains  local  longer  in  man  than  in 
animals,  and  that,  consequently,  more  is  to  be  expected  from  excision  and 
cauterization.     He  recommends  early  excision,  cautery,  and  parenchyma- 


678  PEINCIPLES    OF    SURGERY. 

tous  injections  around  the  area  of  infection  of  a  1-to-lOOO  solution  of 
mercuric  bichloride  or  a  5-per-cent.  solution  of  phenol.  Lengzel  and 
Koranyi  saved  13  out  of  143  cases  by  efficient  local  treatment.  Free  and 
early  excision  and  parenchymatous  injections  of  a  5-per-cent.  solution  of 
carbolic  acid  constitute  the  local  treatment  which  the  average  surgeon 
would  almost  instinctively  resort  to  in  cases  of  accessible  anthracic  in- 
fection. Excision  under  strict  aseptic  precautions  is  also  justifiable  in 
anthrax  oedema,  even  if  all  of  the  infected  tissues  cannot  be  removed,  as 
sterilization  of  the  remaining  portion  of  the  infected  tissues  can  be  secured 
subsequently  more  efficiently  by  parenchymatous  injections  than  if  the 
primary  focus  of  infection  is  allowed  to  remain  as  a  hot-bed  for  pro- 
gressive infection.  In  such  cases  it  would  be  good  practice  to  sear  the 
whole  surface  of  the  wound  with  the  actual  cautery,  for  the  purpose  of 
preventing  general  and  regional  dissemination  by  the  entrance  of  bacilli 
into  the  open  lumina  of  veins  and  lymphatics,  and  also  to  increase  the  re- 
sisting capacity  of  the  tissues  to  infection  by  exciting  an  active  tissue- 
proliferation.  The  actual  cautery  would  prove  successful  in  recent  cases, 
in  cutting  short  an  attack,  if  resorted  to  before  any  considerable  infiltra- 
tion has  occurred.  It  is  said  that  shepherds,  in  districts  where  anthrax 
is  endemic,  destroy  the  vesicle  with  a  red-hot  needle  as  soon  as  it  is  de- 
tected, and  it  is  seldom  that  the  infection  does  not  yield  to  this  treat- 
ment. At  this  early  stage  the  whole  area  of  infection  is  limited,  and 
could  be  most  efi^ectually  destroyed  with  the  sharp  point  of  a  Paquelin 
cautery.  The  general  symptoms  in  severe  cases  of  local  anthrax,  and  after 
general  infection  has  occurred,  resemble  the  clinical  aspects  of  septicaemia 
produced  by  other  causes,  and  patients  suffering  from  general  primary  or 
secondary  anthrax  require  the  same  stimulating,  tonic,  and  supporting 
treatment  that  has  been  laid  down  in  the  treatment  of  septicaemia. 


CHAPTER  XXVII. 


Glandees. 


Synonyms. — Farcy;  equinia;  malleus  humidus;  Morve;  Rotzkrank- 
heit.  A  contagious  disease  characterized  by  multiple  foci  of  inflamjnation 
and  suppuration,  and  caused  by  infection  with  a  specific  microbe:  the 
iacillus  mallei.  The  disease  originates  in  the  horse,  and  occurs  in  men 
by  contagion.  Although  glanders  in  man  is  a  rare  affection,  it  presents, 
from  a  bacteriological  study,  so  many  points  of  interest  that  it  merits 
more  than  a  passing  notice.  It  is  one  of  the  infectious  diseases  whose 
microbic  cause  is  now  thoroughly  understood. 

BACTEEIOLOGICAL    HISTOET    OF   THE    DISEASE. 

That  glanders  in  man  occurred  as  an  infection  from  the  horse  species 
of  animals  has  been  known  for  a  long  time.  Its  contagiousness  among 
horses  was  asserted  by  SoUeysel  in  the  seventeenth  century.  Eindfleisch 
believed  that  he  saw  vibriones  in  the  granular  contents  of  glanderous 
abscesses.  Klebs  detected,  in  cultures  of  pus  taken  from  animals  suffer- 
ing from  this  disease,  small  rods  and  granules,  but  cultivations  and  inocu- 
lations in  rabbits  failed.  The  presence  of  minute  organisms  in  cases  of 
glanders  was  pointed  out  by  Christatt  and  Kiener  in  1868,  and  their  obser- 
vations were  corroborated  by  Bouchard,  Capitan,  and  Charrin,  who  found 
the  organisms  not  only  in  parts  exposed  to  the  air,  such  as  nasal  ulcera- 
tions and  pulmonary  abscesses,  but  also  in  parts  not  so  exposed,  such  as 
the  spleen,  liver,  and  lymphatic  glands.  Chaveau  demonstrated  by  his 
experiments  that  the  virus  of  glanders  was  fixed  to  small,  solid  particles, 
as  he  found  the  sediment,  which  formed  after  diluting  pus  with  water, 
active.  This  discovery  marked  an  advance  in  the  knowledge  of  the  phys- 
ical nature  of  the  virus.  Loffler  and  Schiitz  are  the  discoverers  of  the 
bacillus  of  glanders  in  horses.  In  1882  they  made  a  preliminary  report 
of  their  researches  {Deutsche  med.  WocJienschrift,  1882,  No.  52).  In  1886 
Loffler  published  his  elaborate  monograph  on  this  subject  ("Die  ^tiologie 
der  Rotzkrankheit,"  Arbeiten  aus  dem  Kaiserlichen  Gesundheitsamte  zu 
Berlin,  Bd.  i,  pp.  141-199).  About  the  same  time  0.  Israel  made  cultures 
upon  blood-serum  from  nodules  of  three  glanderous  horses,  with  which  he 
produced  the  disease  artificially  in  rabbits.  The  bacilli  contained  in  these 
cultures  correspond  with  the  description  of  those  isolated  by  Schiitz  and 
Loffler.  Soon  after  Loffler's  first  paper  appeared,  Bouchard,  Capitan,  and 
Charrin  published  almost  simultaneously  the  results  of  their  researches 

(679) 


680  PEINCIPLES    OF    SUEGEEY. 

and  observations;  but  it  appears  from  Loffler's  second  paper  that  none 
of  them  had  been  able  to  produce  a  pure  culture.  Kitt  and  Weichsel- 
baum  were  the  first  who,  by  their  own  investigations,  were  able  to  cor- 
roborate the  correctness  of  Loffler^s  discovery:  the  former  by  his  observa- 
tions and  experiments  on  animals,  the  latter  by  a  case  of  glanders  in  the 
human  subject  that  came  under  his  own  observation. 

DESCEIPTION    OF   BACILLUS    MALLEI. 

According  to  Loffler,  the  bacillus  of  glanders  appears  as  a  small  rod, 
which  is  somewhat  shorter  and  broader  than  the  tubercle  bacillus;  its 
length  varies  but  little,  and  corresponds  to  about  two-thirds  of  the  di- 
ameter of  a  red  blood-corpuscle;  the  thickness  varies  between  one-fifth 
and  one-eighth  of  its  length.    It  is  a  non-motile,  aerobic  microbe. 

These  bacilli  are  either  straight  or  slightly  curved  and  rounded  at 
their  ends.  Usually,  they  are  found  in  pairs  in  a  parallel  direction,  held 
together  by  a  delicate,  unstained  pellicle.  Examined  in  a  drop  of  fluid, 
they  show  active  molecular  movements.     Spontaneous  movements  could 


Fig.  227.— Bacilli  of  Glanders  from  a  Young  Potato  Culture.     X  950.     (Baumgarten.) 

not  be  observed  by  Loffler.  The  colorless  and  sometimes  even  somewhat 
dilated  portions  of  the  stained  bacillus  are  not  spores,  but,  as  Loffler 
affirms,  indications  of  commencing  death.  Loffler  found  that  bacilli  kept 
in  a  dry  state  for  three  months  could  occasionally  be  made  to  grow,  but 
in  most  instances,  after  a  few  weeks,  they  could  no  longer  be  cultivated, 
which  fact  speaks  against  the  existence  of  spores.  On  the  other  hand, 
in  favor  of  the  presence  of  endospores  must  be  regarded  the  results  ob- 
tained by  Eosenthal,  in  Baumgarten's  laboratory,  with  ISTeisser's  method 
of  staining  spores,  who  showed  that  at  least  some  of  the  bacilli  contain 
spores,  while  in  others  the  points  which  refuse  staining  material  are  un- 
doubtedly, as  Loffler  claims,  evidences  of  vacuolar  degeneration. 

(a)  Staining. — The  method  of  staining  the  bacilli  of  glanders  is 
characteristic;  when  the  bacilli  are  treated  by  basic  and  aniline  dyes  no 
effect  is  produced. 

Method  of  Schiitz. — The  sections  are  placed  for  twenty-four  hours 
in  the  following  mixture:  Potash  solution  (1  in  10,000),  concentrated 
alcohol,  methylene-blue  solution:  equal  parts.  Wash  the  sections  in  a 
watch-glass  with  water  acidulated  with  4  drops  of  acetic  acid.     Transfer 


TENACITY    OF    BACILLUS    MALLEI.  681 

for  five  minutes  to  50-per-cent.  alcohol,  clarify  in  clove-oil,  and  mount  in 
Canada  balsam. 

Lbffler's  Method. — Sections  are  immersed  for  a  few  minutes  in  a 
solution  of  potash  (1  in  10,000),  then  for  a  few  minutes  in  an  alkaline 
solution  of  methyl-blue;  after  which  they  are  decolorized  with  a  solution 
of  tropseolin  in  acetic  acid,  or,  what  is  still  better,  in  a  fluid  composed  of 
10  centimetres  of  distilled  water,  2  drops  of  sulphuric  acid,  and  1  drop  of 
a  5-per-cent.  solution  of  oxalic  acid. 

(b)  Cultivation. — When  cultivated  on  solid  sterilized  blood-serum  at 
a  temperature  of  38°  C.  (100.4°  F.),  the  growth  appears  in  the  form  of 
minute  transparent  drops  on  the  surface,  which  consist  exclusively  of  the 
characteristic  bacilli.  Cultures  upon  boiled  potato — according  to  Loftier, 
Kitt,  and  Weichselbaum — form  in  three  days  a  uniform  amber-yellow 
layer,  that  about  the  sixth  to  the  eighth  day  assumes  a  reddish  hue,  resem- 
bling the  color  of  oxide  of  copper,  which  is  not  easily  mistaken  for  anj' 
other  culture  upon  the  same  soil.  Upon  this  nutrient  medium  the  bacilli 
were  cultivated  through  twelve  generations,  and  the  cultures  retained 
their  activity  for  a  year;  whether  the  bacillus  was  capable  of  cultivation 
after  this  time  is  not  mentioned.  The  temperature  at  which  cultures  could 
be  made  to  grow  varied  from  30°  to  40°  C.  (86°  to  104°  F.).  The  bacillus 
also  grows  in  neutralized  bouillon,  with  and  without  the  addition  of  pep- 
tone. The  culture  first  renders  the  fiuid  turbid,  and,  later,  settles  on  the 
bottom  of  the  vessel  as  a  white,  shining  mass.  Weichselbaum  succeeded 
in  growing  the  bacillus  upon  ordinary  nutrient  agar  and  gelatin.  Easkina 
rendered  these  nutrient  media  more  fertile  for  the  growth  of  this  microbe 
by  the  addition  of  chicken-matron  albuminate.  Kranzfeld  succeeded  best 
with  Nocard  and  Roux's  mixture:  meat-peptone,  glycerin-agar-agar. 

TENACITY    OF    BACILLUS    MALLEI. 

Loffler  ascertained  that  this  bacillus  shows  the  same  degree  of  re- 
sistance to  heat  and  germicidal  substances  as  other  bacilli  without  spores. 
The'  bacillus  is  destroyed  by  exposure  for  ten  minutes  to  a  temperature  of 
55°  C.  (131°  F.).  It  is  also  destroyed  by  a  3-  to  5-per-cent.  solution  of 
carbolic  acid  in  five  minutes,  and  in  two  minutes  in  a  l-to-5000  solution  of 
corrosive  sublimate.  Bonome  has  drawn  the  following  conclusions  from 
his  studies  concerning  the  life-history  of  the  bacillus  of  glanders:  1.  The 
bacillus  is  present  in  all  glanderous  inflammatory  products  and  in  the 
urine  and  milk  of  the  diseased  animals.  2.  It  can  pass  from  mother  to 
foetus  through  a  healthy  placenta.  3.  It  is  very  susceptible  to  the  de- 
structive influences  of  desiccation.  It  loses  its  virulence  when  kept  in  a 
dry  state  at  a  temperature  between  25°  and  30°  C.  in  the  absence  of  other 


683  PEINCIPLES    OF    SURGERY. 

organic  matter,  and  ceases  to  grow  if  the  drying  process  is  continued  for 
more  than  ten  days.  4.  If  the  drying  process  is  imperfect,  as  is  the  case 
in  an  old  agar  culture,  the  virulence  is  retained  for  several  weeks.  In  dis- 
tilled water  the  bacillus  dies  in  from  five  to  six  days.  5.  It  offers  a  rela- 
tively great  resistance  to  heat.  6.  Cadaverin  in  the  proportion  of  1  to 
40,000  or  1  to  60,000  causes  the  bacilli  to  grow  in  long  filaments  and  de- 
prives them  of  their  pathogenic  properties.  7.  The  bacillus  does  not  grow 
in  the  serum  of  a  glanderous  horse.  8.  In  normal  ox-serum  the  bacillus 
presents  almost  the  same  phenomena;  this  serum,  filtered  after  the  pro- 
longed contact  with  the  bacilli,  possesses  curative  properties  against  the 
disease  in  certain  animals.  9.  The  serum  of  dogs  collected  during  the 
treatment  with  mallein  is  an  unfavorable  medium  for  the  growth  of-  the 
organism.  This  may  explain  the  protective  influence  against  the  disease 
in  this  animal. 

INOCULATION"   EXPERIMENTS. 

Kitt  enumerates  the  following  animals  as  being  susceptible  of  inocu- 
lation with  the  virus  of  glanders:  Tiger,  lion,  cat,  sheep,  goats,  guinea- 
pigs,  horse,  ass,  rabbits,  and  white  rat.  Pigs,  dogs,  the  common  rat,  ducks, 
and  chickens  possess  great  immmunity;  the  inoculations  at  best  produce 
only  a  slight  local  reaction.  LofSer  made  his  first  experiments  on  guinea- 
pigs  and  the  field-mouse.  In  the  guinea-pigs  he  observed,  three  to  five 
days  after  subcutaneous  injection  of  a  pure  culture,  an  ulcer  at  the  point 
of  inoculation,  and  at  the  end  of  the  first  week  swelling  of  the  nearest 
lymphatic  glands,  attended  by  suppuration.  At  this  stage  of  the  disease 
the  process  often  came  to  a  stand-still  and  the  animals  recovered.  In 
many  animals  the  disease  progressed  quite  rapidly  to  a  fatal  termination. 
Abscesses  were  frequently  found  in  the  testicle  and  the  epididymis  in  the 
male,  and  in  the  breast  and  external  genital  organs  of  the  female.  The 
face,  nasal  cavity,  and  ankle-joint  were  also  frequently  the  seat  of  ulcera- 
tive processes.  In  case  the  disease  proved  fatal,  death  usually  occurred 
three  or  four  weeks  after  inoculation.  At  the  post-mortem,  aside  of  the 
affections  enumerated,  nodules  were  found  in  the  spleen,  lungs,  and  fre- 
quently in  the  liver.  The  histological  structure  of  a  recent  nodule  bears 
a  great  resemblance  to  tubercle.  The  bacilli  are  always  found  more 
numerous  in  the  nodules  if  the  disease  is  produced  artificially  by  inocula- 
tion. The  inflammatory  product  is  first  composed  almost  exclusively  of 
epithelioid  cells,  between  which  leucocytes  from  the  periphery  insinuate 
themselves.  Giant  cells  are  never  found  in  glanderous  nodules;  the  epi- 
thelioid cells  are  derivatives  of  connective  tissue  and  endothelial  cells; 
while  the  leucocytes  escape  from  the  inflamed  capillary  vessels.  Baum- 
garten  constantly  observed  karyokinetic  figures  in  the  epithelioid  cells. 


INOCULATION    EXPEEIMENTS.  683 

The  leucocytes  that  enter  the  nodule  soon  show  evidences  of  frag- 
mentation^ and  are  converted  into  pus-corpuscles.  The  bacilli  are  dis- 
tributed among  the  cellular  elements  singly,  in  pairs,  and  in  groups.  Some 
of  them  may  be  seen  also  within  the  cellular  elements,  especially  the 
•epithelioid  cells. 

Field-mice  proved  a  great  deal  more  susceptible  to  the  virus  of  glan- 
ders than  guinea-pigs,  as  they  usually  died  three  or  four  days  after  in- 
oculation.    The  necropsy  in  these  animals  showed,  at  the  point  of  inocu- 


r 


■^ 


o©(.^^        ""  ^-(&e°l=i^^^    ''"'^''^lo    0'''«!'5."  0    fl   '»>S- 


o 


Fig.  228. — Glanderous  Nodule  from  the  Liver  of  a  Field-mouse.  (Bismarck-brown 
staining.  Bacilli  stained  after  LofBer's  method.  Bacilli  magnified  and  drawn  twice 
this  size.)     K,  karyokinetic  figures  in  epithelioid  cells.     X  250.     (Baumgarten.) 

lation,  an  infiltration  from  which  swollen  lymphatic  vessels  led  to  the 
nearest  lymphatic  glands.  In  the  spleen  and  liver,  which  were  always 
found  greatly  enlarged,  numerous  small  nodules  could  be  seen,  while  the 
remaining  internal  organs  presented  a  normal  appearance.  Glanders  in 
guinea-pigs  and  field-mice  presents  a  series  of  pathological  changes  that 
cannot  be  mistaken  for  any  other  affection.  The  bacilli  of  glanders  in 
the  different  organs  can  be  detected  most  readily  in  recent  specimens. 
In  the  blood  bacilli  were  detected  only  in  very  acute  cases:    a  circum- 


684  PEINCIPLES    OF    SURGEKY. 

stance  that  explains  why  so  many  inoculations  with  the  blood  of  glander- 
ous horses  proved  unsuccessful.  The  bacilli  of  glanders  are  evidently 
strictly  tissue-,  and  not  blood-,  parasites. 

Lundgren  took  a  nodule  from  the  lungs  of  a  horse  that  had  died  of 
glanders,  and  implanted  fragments  of  it  under  the  skin  of  rabbits.  The 
animals  died  about  the  nineteenth  day  after  inoculation,  and  the  necropsy 
revealed  induration  and  small  abscesses  at  the  point  of  infection,  and 
small,  yellow  nodules  in  the  spleen,  liver,  lungs,  testicles,  and  mucous 
membrane  of  the  nose.  Implantation  of  spleen-tissue  into  other  rabbits 
fixed  the  period  of  incubation  in  this  animal  at  from  eleven  to,  twelve  days. 

Kranzfeld  has  published  the  results  he  obtained  by  inoculations  with 
the  virus  of  glanders  in  an  animal  hitherto  not  subjected  to  experimenta- 
tion of  this  kind.  He  procured  a  pure  culture  from  a  nodule  of  a  man  who 
had  died  of  glanders  after  a  brief  illness.  Inoculations  were  made  in  a 
small  rodent  which  is  very  numerous  in  the  southern  part  of  Eussia,  the 
Spennophilus  guttatus.  The  course  of  the  disease  in  this  animal  was  al- 
most the  same  as  in  the  field-mice  that  were  used  by  Lotiler.  Of  28  ani- 
mals infected  with  different  cultures,  16  died  on  the  fourth  day,  9  on  the 
fifth,  2  on  the  seventh,  and  1  on  the  tenth.  The  post-mortem  appearances 
were  always  characteristic:  a  greenish-gray  infiltration  at  the  point  of 
inoculation  and  a  number  of  nodules  in  the  spleen;  in  one  animal  also  very 
small,  white  nodules  in  the  liver.  Cultivations  from  these  nodules  yielded 
a  pure  growth  of  the  bacillus  of  glanders.  If  animals  are  infected  by 
direct  injection  of  a  pure  culture  into  a  vein,  no  serious  symptoms  are 
produced;  but,  if  soon  thereafter  one  or  more  muscles  are  injured  sub- 
cutaneously,  the  microbes  escape  through  the  lacerated  vessels,  localize  at 
the  seat  of  injury,  and  produce  a  grave  form  of  the  disease.  It  has  been 
determined  by  experiment  that  the  farther  from  the  trunk  the  inocula- 
tions are  made,  the  less  intense  is  the  local  reaction.  When  an  animal  is 
inoculated  at  a  distance  from  the  trunk,  and  shows  no  general  symptoms, 
a  subcutaneous  injury  of  any  portion  of  the  trunk  will  furnish  the  neces- 
sary conditions  for  the  development  of  a  local  form  of  infection. 

It  had  been  generally  believed  that  the  intact  skin  furnished  an 
adequate  protection  against  infection  with  the  bacillus  of  glanders  until 
the  experiments  of  Babes  and  Nocard  proved  that  infection  can  take  place 
through  the  healthy  skin.  Nocard  rubbed  a  pure  culture  of  the  bacillus  into 
the  skin  in  two  guinea-pigs,  and  found  on  the  fifteenth  day  some  of  the 
hair-follicles  the  seat  of  glanderous  inflammation.  Histological  examination 
showed  numerous  bacilli  in  the  follicles,  the  epithelial  layer  much  thickened, 
and  the  surrounding  connective  tissue  in  a  state  of  proliferation.  The  infec- 
tion had  extended  from  the  follicles  through  the  connective  tissue  into  the 
lymphatic  vessels  underneath,  as  was  evident  from  the  presence  of  bacilli  in 


GLANDERS    IN    THE    HORSE.  685 

tlie  lymphatic  glands,  vessels,  and  connective-tissue  spaces  in  the  immediate 
vicinity  of  the  primary  lesion  of  the  skin. 

GLANDERS  IN  THE  HORSE. 

Glanders  and  farcy  in  the  horse  are  different  manifestations  of  the 
same  disease,  and,  as  each  of  them  is  divided  into  an  acute  and  chronic 
form,  we  find  described  four  varieties  of  the  disease  in  this  animal:  acute 
and  clironic  glanders,  acute  and  clironic  farcy. 

Acute  Glanders. — This  form  of  glanders  is  attended  by  a  high  tem- 
perature (106°  to  109°  F.)  and  other  symptoms  of  acute  sepsis,  and  proves 
uniformly  fatal  in  a  few  days.  The  breathing  is  accelerated,  the  pulse 
feeble  and  rapid,  and  there  is  complete  loss  of  appetite.  The  nasal  mu- 
cous membrane,  at  first  of  a  dark,  coppery  color,  with  dark-red  ecchymotic 
patches^  becomes  purple;  these  ecchymoses  are  rapidly  converted  into 
ulcers,  from  which  issues  a  copious  sero-sanguinolent  discharge.  Lym- 
phatic infection  is  a  characteristic  feature  of  acute  glanders.  The  sub- 
maxillary and  cervical  glands  enlarge  and  suppurate,  discharging  unhealthy- 
looking,  ichorous  pus.    Abscesses  also  form  in  the  lymphatics  of  the  face. 

Chronic  Glanders. — This  is  the  form  most  commonly  seen  in  the  horse. 
The  disease  begins  in  the  mucous  membrane  of  the  nose.  Small,  whitish 
nodules,  composed  of  small,  round  cells,  are  formed  in  the  mucous  mem- 
brane. These  nodules  soften  and  ulcerate.  Similar  nodules  may  be  found 
in  the  larynx,  trachea,  and  bronchi.  The  ulcerations  may  remain  super- 
ficial, or  they  may  extend  to  the  deep  tissues,  even  attacking  cartilage 
and  bone.  The  internal  organs,  especially  the  lungs,  may  become  the 
seat  of  metastatic  foci.  The  left  nostril  appears  to  be  affected  more  fre- 
quently than  the  right.  The  lymphatic  glands  underneath  the  lower  jaw  en- 
large very  rapidly,  often  reaching  considerable  dimensions  during  a  single 
night.  The  glandular  swellings  may  continue  for  several  days,  afterward 
slowly  disappear,  and  then  reappear  as  rapidly  as  before.  The  discharge 
from  the  nostrils  presents  a  starchy  or  glue-like  appearance,  adheres  to 
the  mucous  membrane,  where  it  dries  and  accumulates,  causing  narrowing 
of  the  nasal  opening. 

Acute  Farcy. — Acute  farcy,  together  with  chronic  farcy,  is  simply  an- 
other manifestation  of  glanders,  and  is  initiated  in  a  very  similar  manner 
to  acute  glanders.  There  are  the  same  lesions  of  the  lymphatics  and 
nodules,  and  abscesses  are  found  in  the  skin.  A  general  swelling  of  the 
cutaneous  tissues  takes  place,  varying  in  size  for  a  time,  but  suddenly  a 
number  of  distinct  swellings  or  nodules  will  appear,  termed  "farcy-buds." 
These  specific  nodules,  so  characteristic  of  farcy  in  either  its  acute  or 
chronic  form,  involve  the  skin,  subcutaneous  connective  tissue,  or  they 
may  extend  to  the  deeper  tissues.     They  vary  in  size  from  a  pea  to  a 


686  PKINCIPLES    OF    SUEGEEY. 

hazel-nut.  These  nodules  suppurate,  and,  after  evacuation  of  their  con- 
tents '  leave  ragged  ulcers  that  discharge  a  foul,  grayish-white,  creamy- 
liquid  tinged  with  blood.  When  several  ulcers  are  in  close  proximity 
they  may  become  confluent  and  form  an  extensive  ulcerating  surface. 
With  the  appearance  of  the  nodules  the  lymphatics  become  inflamed, 
swollen,  and  indurated.  Not  infrequently  acute  farcy  terminates  in  the 
development  of  acute  glanders,  with  all  the  pathological  conditions  that 
have  been  described  as  characteristic  of  that  disease,  thus  showing  their 
etiological  identity. 

Chronic  Farcy. — In  this  form  of  glanders  the  lymphatic  glands  are 
principally  involved.  The  disease  is  not  attended  by  much  febrile  dis- 
turbance, and  all  of  the  other  general  symptoms  are  less  marked  than  in 
the  other  varieties  of  glanders.  The  lymphatic  glands  become  enlarged,, 
and  nodules  are  formed  in  the  skin,  lungs,  and  other  viscera.  Central 
softening  and  suppuration  of  the  nodules  is  a  regular  occurrence.  Long,, 
fistulous  tracts  often  result  from  extensive  undermining  of  the  skin.  In 
all  of  these  different  forms  of  glanders  in  the  horse  the  cause  remains  the 
same,  and  the  pathological  conditions  are  identical;  only  the  clinical  as- 
pects vary  from  the  location,  intensity,  and  extent  of  the  primary  infection. 

GLANDEES    IN   MAN.  ^ 

In  man  the  disease  occurs  in  an  acute  and  chronic  form,  but  does  not 
exactly  resemble  any  of  the  varieties  of  the  disease  in  the  horse  or  the 
disease  artificially  produced  in  animals  by  inoculation.  The  discharge 
from  the  nostrils  of  a  diseased  horse,  brought  in  contact  with  an  abraded 
surface  or  a  mucous  membrane,  Avill  communicate  the  disease.  IsTocard 
made  experiments  to  determine  whether  the  bacillus  of  glanders  could 
enter  the  intact  skin.  He  rubbed  a  pure  culture  of  the  microbe  into  the 
sikn  of  3  asses  and  15  guinea-pigs.  Of  the  18  animals  only  2  guinea-pigs 
were  infected,  and  it  is  probable  that,  in  these,  infection  occurred  through 
minute  excoriations  of  the  skin.  Notwithstanding  the  positive  results  that 
followed  the  cutaneous  inoculations  in  guinea-pigs  with  a  pure  culture 
of  the  bacilli  of  glanders  by  Nocard,  it  is,  for  all  practical  purposes,  safe 
to  make  the  assertion  that  the  virus  of  glanders  can  only  find  entrance 
into  the  organism  through  a  wounded  surface.  Whether  infection  may 
not  take  place  through  the  alimentary  canal  has,  so  far,  not  been  definitely 
ascertained.  It  is  certain  that  the  disease  cannot  be  contracted  by  eating- 
boiled  or  fried  fiesh  of  animals.  Infection  through  the  respiratory  organs 
is  possible,  as  cases  have  been  reported  in  which  the  lungs  were  the  pri- 
mary and  only  seat  of  the  disease.  The  fact  that  man  can  be  infected 
with  a  pure  culture  of  the  bacilli  of  glanders  as  successfully  as  the  animals- 


SYMPTOMS   AND   DIAGNOSIS.  687 

that  have  been  successfully  experimented  on  received  a  sad  illustration 
a  number  of  years  ago  in  Vienna. 

Dr.  Hoffmann,  a  young  and  promising  physician,  who  was  making 
some  experimental  investigations  on  animals  with  pure  cultures,  accident- 
ally inoculated  himself  with  the  needle  used  for  making  the  inoculations, 
and  died  from  acute  glanders  in  a  few  days.  Observations  of  veterinary 
surgeons  and  experimental  researches  have  shown  conclusively  that  the 
disease  can  be  transmitted  from  the  mother  to  the  foetus  in  utero  by  pas- 
sage of  the  bacilli  through  the  placenta  from  the  maternal  into  the  foetal 
circulation.  When  man  is  the  subject  of  glanders,  bacilli  are  found  more 
constantly  in  the  blood  than  in  glanderous  animals.  In  the  case  described 
by  Weichselbaum,  numerous  bacilli  could  be  seen  in  the  blood.  In  this 
case  a  thrombus  was  found  in  one  of  the  large  meningeal  veins,  contain- 
ing numerous  bacilli,  and  which,  undoubtedly,  was  one  of  the  sources  of 
the  bacilli  in  the  circulation.  In  man  the  nasal  mucous  membrane  is  not 
so  frequently  affected  as  in  animals,  although  Bollinger  has  shown  that 
in  horses  the  nasal  cavity  is  not  always  affected,  and  that  it  may  present 
a  normal  condition,  even  when  the  larynx  and  lungs  are  seriously  affected. 
Muscular  abscesses,  that  may  simulate  rheumatism,  are  of  very  frequent  oc- 
currence, especially  in  the  chronic  form  of  the  disease. 

SYMPTOMS   AND   DIAGNOSIS. 

The  symptomatology  of  glanders  is  variable,  as  it  is  greatly  modified 
by  the  intensity  of  the  infection,  the  primary  location  of  the  disease,  and 
the  number  and  distribution  of  the  metastatic  foci.  The  disease  may 
begin  at  a  single  point,  and  may  then  be  mistaken  for  a  carbuncle  or  a 
gangrenous  erysipelas.  Graefe  reports  a  case  which  began  as  an  acute 
exophthalmos,  and  the  nature  of  the  disease  was  not  ascertained  until 
after  death.  In  this  case  there  were  nodules  in  the  choroid  of  the  eye. 
Acute  glanders  runs  a  rapid  and  malignant  course.  Infection  usually 
takes  place  through  a  small  wound,  puncture,  or  abrasion  about  the  face 
or  hands.  At  the  point  of  inoculation  a  somewhat  elongated,  soft,  in- 
flammatory swelling  or  nodule  forms  in  a  few  days.  Central  softening 
and  suppuration  soon  transform  the  inflammatory  product  into  an  under- 
mined ulcer,  with  irregular,  ragged  margins,  surrounded  by  a  wall  of 
infiltration.  In  mild  cases  the  disease  may  remain  local,  and  the  ulcer 
heals  under  proper  treatment  in  a  few  weeks.  In  other  cases  regional  in- 
fection takes  place,  and  the  lymphatic  glands  become  swollen  and  sup- 
purate, leaving  the  same  kind  of  ulcers  as  at  the  primary  seat  of  infection. 

In  the  fatal  cases  general  infection  takes  place  either  through  the 
veins  or  the  lymphatic  vessels,  and  the  symptoms  then  resemble  septi- 
caemia or  pyaemia,  or  a  combination  of  these  two  diseases:    septopyEemia. 


688  PEINCIPLES    OF    SUEGERT. 

Errich  reports  a  case  of  glanders  which  was  remarkable  for  the  fact  that 
the  elbow-^  knee-,  and  ankle-  joints  were  the  seat  of  pyasmic  suppuration. 
Forestier  describes  a  case  in  which  numerous  subcutaneous  abscesses  ap- 
peared which  contained  hsemorrhagic  pus.  Brault  and  Eouget  observed  a 
case  in  which  seventeen  subcutaneous  abscesses  appeared  and  four  large 
joints  were  the  seat  of  suppurative  inflammation.  If  infection  take  place 
directly  through  the  veins,  a  thrombophlebitis  develops  in  connection  with 
one  of  the  nodules  and  the  bacilli  in  the  thrombvis,  which  multiply  in  this 
nutrient  medium  and  gain  entrance  into  the  general  circulation  singly  or 
through  the  medium  of  infected  emboli.  Under  such  circumstances, 
nodules  are  found  in  the  lungs,  kidneys,  and  other  internal  organs,  as  sup- 
purating metastatic  deposits  in  muscles,  bone,  joints,  and  testicle.  In  such 
cases  the  general  symptoms  may  simulate  to  perfection  typhoid  fever, 
pygemia,  suppurative  osteomyelitis,  and  acute  general  miliary  tuberculosis. 
In  acute  cases  where  general  infection  occurs  early  and  rapidly,  death  re- 
sults in  from  one  to  three  or  four  weeks,  while  in  chronic  cases  the  final 
fatal  termination  is  often  postponed  for  months.  In  illustration  of  the 
clinical  history  of  this  disease  I  will  quote  briefly  a  few  cases. 

A  Eussian  medical  journal  of  recent  date  states  that  a  young  soldier, 
who  had  been  a  wagoner  before  his  admission  into  the  army,  was  received 
into  the  military  hospital  suffering  from  two  foul  ulcers  on  the  hard 
palate,  which  had  perforated  the  nasal  fossa  and  destroyed  the  inferior 
turbinated  bones.  Three  weeks  later  a  swelling  appeared  over  the  eye- 
brow; a  fortnight  afterward  he  complained  of  pain  on  the  inner  side  of 
the  left  knee,  around  the  internal  tuberosity  of  the  tibia.  A  purulent 
discharge  occurred  from  the  left  ear,  and,  at  the  same  time,  an  abscess 
developed  on  the  back  of  the  right  hand  which  appeared  as  a  deep-purple 
tubercle,  with  a  hard  circumference,  and  sunken  toward  the  centre;  a 
purulent  discharge  oozed  from  the  surface;  at  first,  for  a  short  time  after 
admission,  the  temperature  varied,  rising  in  the  evening  to  103°-104°  F.; 
later  on  it  fell  to  normal.  The  disease  was  mistaken  for  syphilis,  and 
iodide  of  potassium  was  given  without  the  least  benefit.  About  ten  weeks 
after  admission  he  was  in  better  health,  and  left  the  hospital,  receiving 
his  discharge  from  the  army.  Within  a  few  weeks  he  returned,  with  ex- 
tension of  ulceration  of  the  hard  palate;  the  uvula  was  destroyed.  The 
characteristic  nodules,  the  "farcy-buds,"  appeared  in  the  face;  the  meta- 
static abscess  on  the  back  of  the  hand  remained.  The  patient  ultimately 
died  of  exhaustion.  Before  death  some  of  the  nodules  were  extirpated; 
they  were  found  to  contain  microorganisms  resembling  to  perfection  the 
bacillus  of  Lofiler  and  Schlitz. 

Klittner  rei^orts  a  number  of  cases  in  which  the  skin  was  the  seat 
of  numerous  points  of  suppuration  in  the  form  of  pustules,  or  more  dif- 


SYMPTOMS   AND   DIAGNOSIS.  689 

fuse  abscesses  followed  by  ulceration.  The  disease  has  been  mistaken 
more  frequently  for  syphilis  than  any  other  affection.  This  mistake  in 
diagnosis  is  very  liable  to  be  made  in  the  chronic  form,  in  which  the 
nodules  grow  very  slowly,  are  hard,  and  may  occur  in  groups  or  like  a 
string  of  beads.  The  nodules  usually  soften  and  form  chronic  ulcers, 
which  closely  resemble  the  ulcers  resulting  from  the  breaking  down  of 
gummata.  If  the  disease  primarily  attack  the  nasal  cavity,  the  mucous 
membrane  presents  hard  nodules,  and  a  copious  discharge  from  the  nose 
is  present.  In  acute  glanders  affecting  the  nose  and  face,  extensive  de- 
struction of  tissue  by  the  rapid  breaking  down  of  the  nodules  is  one  of 
the  prominent  clinical  features  of  the  disease.  Complete  destruction  of 
the  nose,  with  formation  of  large  ulcers  of  the  face,  may  happen  in  the 
course  of  a  week. 

Chronic  glanders  may  also  be  easily  mistaken  for  tuberculosis  of  the 


Fig.  229. — Acute  Glanders,  Involving  Nose  and  Face,   showing  Extent  of  Local  Lesions 
Bight  Days  after  the  Commencement  of  the  First  Symptoms.     (.Birch-Hirschfeld.) 


skin,  mucous  membranes,  and  lymphatic  glands.  Buschke  describes  a  case 
of  chronic  glanders  localized  in  one  extremity,  this  being  the  fifth  recorded 
case.  Acute  glanders  may  simulate  furuncle,  carbuncle,  and  other  sup- 
purative lesions,  as  well  as  lymphangitis  and  erysipelas.  In  making  a 
differential  diagnosis  between  these  different  affections  and  glanders,  it  is 
important,  if  possible,  to  trace  the  infection  to  its  proper  source.  If  the 
clinical  history  point  to  the  possibility  of  infection  by  contact  with  a 
glanderous  horse,  it  should  be  remembered  that  the  period  of  incubation 
in  man  varies  from  two  days  to  three  weeks.  A  positive  diagnosis  must 
necessarily  rest  on  the  detection  of  the  specific  microbe  in  the  granulation- 
tissue  or  in  the  discharges,  and  the  results  obtained  by  inoculation  ex- 
periments. The  method  of  inoculation  as  an  aid  in  diagnosis,  proposed  by 
Strauss,  is  of  great  value.    This  consists  in  the  injection  of  cultures  or  of 


690  PRINCIPLES    OF    SUEGEEY. 

the  suspected  crude  products  into  the  peritoneal  cavity  of  a  male  guinea- 
pig.  If  the  disease  is  glanders,  a  positive  diagnosis  can  be  made  within 
three  or  four  days.  At  the  end  of  this  time  the  scrotum  is  red  and  glossy, 
the  cuticle  desquamates,  and  suppuration  occurs.  The  bacillus  of  glanders 
can  be  found  in  the  pus.  The  animal  usually  dies  in  the  course  of  twelve 
to  fifteen  days.  When  the  animal  is  killed  three  or  four  days  after  the 
inoculation  suppuration  of  the  testicle  and  its  envelopes  can  be  demon- 
strated and  the  bacillus  of  glanders  is  invariably  present  in  the  products 
of  the  suppurative  inflammation.  As  soon  as  general  infection  has  taken 
place,  the  symptoms  resemble  pyaamia  or  septicsemia;  so  that  a  differen- 
tial diagnosis  between  metastatic  glanders  and  general  infection  with  pus- 
microbes  cannot  be  made  without  the  aid  of  the  microscope  and  inocula- 
tion experiments. 

PATHOLOGY   AND   MORBID   ANATOMY. 

The  bacillus  of  glanders  resembles,  in  its  immediate  action  on  the 
tissues,  both  the   bacillus   of  tuberculosis   and   the   pus-microbes.      The 


:.© 


Fig.  230.— Section  of  a  Glanders  Nodule.     X  700.     (Flugge.) 

histological  change  first  observed  in  the  infected  tissues  is  a  transforma- 
tion of  mature  into  embryonal  tissue,  the  microscopical  picture,  with  the 
exception  of  the  absence  of  giant  cells,  resembling  tubercle;  but  this  stage 
is  of  short  duration,  as  the  pyogenic  effect  of  the  bacillus  of  glanders  soon 
produces  purulent  softening  by  the  speedy  conversion  of  the  embryonal 
cells  and  leucocytes  into  pus-corpuscles.  The  formation  of  abscesses  is 
a  constant  occurrence,  wherever  localization  has  taken  place,  either  by 
direct  infection,  secondary  infection  from  regional  diffusion  through  the 
lymphatic  vessels  and  connective-tissue  spaces,  or  by  general  infection 
by  embolic  diffusion  through  the  general  circulation. 

As  soon  as  the  disease  has  become  general,  the  clinical  picture  and 
pathological  conditions  are  the  same  as  in  pysemia  caused  by  a  suppu- 


TEEATMENT.  691 

rative  lesion.  The  differentiation  between  the  two  forms  of  metastasis 
can  be  made  only  by  demonstrating  the  primary  cause,  by  use  of  the 
microscope  or  by  the  results  obtained  from  inoculation  experiments.  The 
pus  found  in  glanders  is  grayish  red  in  color,  and  quite  tenacious  in  recent 
lesions,  but  after  opening  the  abscesses  it  assumes  the  character  of  ordi- 
nary pus,  as  the  abscess-cavities  then  become  the  seat  of  secondary  in- 
fection with  pus-microbes.  Swelling  and  abscesses  of  the  testicles  have 
been  frequently  observed  in  cases  where  the  disease  has  become  general, 
the  affection  in  these  organs  being  one  of  the  clinical  manifestations  that 
embolic  dissemination  has  occurred.  Primary  glanders  of  the  lungs  from 
inhalation  of  the  microbes  into  the  air-passages  gives  rise  to  symptoms 
and  pathological  conditions  that  cannot  be  distinguished  from  pulmonary 
tuberculosis,  unless  the  essential  cause  can  be  demonstrated  in  the  sputa 
under  the  microscope,  or  glanders  can  be  artificially  produced  by  the  in- 
jection of  sputum  into  the  subcutaneous  tissue  or  the  peritoneal  cavity 
of  guinea-pigs.  The  pulmonary  nodules  soften  and  suppurate,  and  cavities 
form  in  the  same  manner  as  in  pulmonary  tuberculosis. 

PEOGNOSIS. 

The  prognosis  in  glanders  should  always  be  guarded,  as  a  limited 
local  lesion  may  be  followed  by  a  fatal  form  of  general  infection.  The 
prognosis  is  comparatively  favorable  if  the  infection  remain  limited  to 
a  circumscribed  area  accessible  to  direct  surgical  treatment.  It  must  be 
more  guarded  if  regional  infection  through  the  lymphatic  vessels  has 
occurred,  and  it  is  absolutely  fatal  in  cases  of  primary  glanders  of  im- 
portant internal  organs,  and  when  general  infection  has  followed  in  the 
course  of  a  local  lesion  with  or  without  regional  dissemination.  In  the 
local  form  of  the  disease  the  ulcerations  usually  prove  inveterate  to  treat- 
ment, and  the  final  recovery  is  often  retarded  for  months  b}^  extensive 
undermining  of  the  skin.  Acute  glanders  with  general  infection,  as  a  rule, 
proves  fatal  within  one  to  three  weeks,  and  death  occurs  in  consequence 
of  septic  infection. 

TREATMENT. 

The  prophylactic  treatment  consists  in  preventing  infection  from 
glanderous  horses  and  substances  which  have  become  contaminated  with 
the  specific  virus  from  diseased  animals,  and  requires  early  recognition 
of  the  disease  and  killing  of  the  affected  animals,  as  well  as  thorough 
disinfection  of  the  premises  occupied  by  the  diseased  beast.  The  ca- 
davers should  be  cremated  or  deeply  buried.  Abrasions  or  granulating  sur- 
faces that  have  been  exposed  to  infection  should  be  cauterized. 

In  cases  of  primary  pulmonary  or  intestinal  glanders,  and  after  gen- 


692  PRINCIPLES    OF    SUEGERY. 

eral  infection  from  a  local  form  of  the  disease  lias  occurred,  the  treatment 
must  be  necessarily  symptomatic,  as  such  cases  are  beyond  the  reach  of 
local  or  general  treatment.  The  embarrassed  respiration  and  feeble  and 
rapid  pulse  indicate  the  use  of  alcoholic  stimulants.  A  primary  nodule 
should  be  removed  by  excision,  taking  all  necessary  precautions  to  pre- 
vent infection  of  the  wound  in  case  the  skin  has  been  destroyed  by  ulcera- 
tion. Limited  regional  infection  should  be  treated  in  the  same  manner 
if  ulceration  has  not  taken  place,  and  the  conditions  are  such  that  all  of 
the  infected  tissues  can  be  removed  with  safety. 

Gold  reports  two  cases  of  glanders  in  man  cured  by  mercurial  in- 
unctions. In  one  of  these  cases  sixty-two  inunctions  were  made.  He 
states  that  he  has  observed  about  thirty  cases  of  glanders,  and  that,  with 
the  exception  of  the  two  treated  by  this  method,  all  proved  fatal.  All 
subcutaneous  abscesses  were  duly  opened  and  washed  out  with  a  l-to-500 
solution  of  corrosive  sublimate.  All  ulcers  were  similarly  disinfected  with 
the  lotion,  then  painted  with  nitric  acid  and  dressed  antiseptically.  The 
total  quantity  of  mercurial  ointment  rubbed  into  the  patient  in  the  course  of 
sixty-five  days  amounted  to  1  pound,  1  ounce,  and  3  drachms.  The  treat- 
ment with  mallein  does  not  appear  to  have  yielded  the  expected  results,  as 
J.  Bates  reports  four  cases  treated  by  this  antitoxin  with  negative  results. 

After  multiple  abscesses  have  formed  a  radical  operation  is  no  longer 
indicated,  the  extent  of  the  affection  precluding  the  possibility  of  removing 
all  of  the  infected  tissues.  In  such  cases  the  abscesses  should  be  freely 
incised,  fistulous  tracts  laid  open,  undermined  skin  cut  away,  and,  as  far 
-as  possible,  the  infected  tissues  removed  with  a  sharp  spoon;  then  the 
■entire  surface  should  be  disinfected  with  a  12-per-cent.  solution  of  chlo- 
ride of  zinc.  No  attempt  should  be  made,  under  such  circumstances,  to 
obtain  healing  of  the  superficial  wounds  until  it  becomes  apparent  that 
the  specific  microbic  cause  has  been  eliminated  or  destroyed,  and  several 
repetitions  of  the  curetting  and  disinfection  may  become  necessary  until 
this  object  is  realized.  The  scraped  surfaces  should  be  kept  covered  with 
a  moist  antiseptic  gauze  compress,  wrung  out  of  l-to-2000  solution  of 
corrosive  sublimate  or  a  3-per-cent.  solution  of  carbolic  acid.  If  the  pro- 
longed use  of  these  antiseptics  is  objectionable  on  account  of  danger  from 
absorption  of  toxic  doses  of  these  drugs,  strong  iodine-water  can  be  used 
in  the  same  way.  The  internal  use  of  iodine,  creasote,  and  arsenic  has 
been  recommended  as  specifics  in  the  treatment  of  glanders,  but  clinical 
experience  has  not  supported  this  claim,  and  the  surgeon  must  rely  upon 
local  measures  in  his  efforts  to  protect  the  patient  against  the  dangers 
arising  from  regional  and  general  infection;  while  he  must  aim,  at  the 
same  time,  to  maintain  the  resisting  power  of  the  tissues  to  the  microbic 
invasion  by  a  supporting  tonic  and  stimulating  treatment. 


INDEX. 


Abnormal  and  defective  callus,  57 
Abscess,   248 
acute,  250 

diagnosis,  251 

treatment,  253 
chronic,  254 

diagnosis,  255 

treatment,  255 
iliac,  512 
lumbar,  512 
of  brain,  323 

cerebral  localization,  325 

prognosis,  324 

symptoms  and  diagnosis,  323 

treatment,  322 
of  internal  organs,  309 
of  lung,  diagnosis,  338 

exploration,  339 

operation,  340 
psoas,  512 
tubercular,  509 

pathological  anatomy,  509 

prognosis,  513 

symptoms  and  diagnosis,  511 

treatment,  513 
Absolute  asepsis,  23 
Accurate  suturing,  26 
Achromatin,  8 
Actinomycosis  hominis,  619 
clinical  varieties,  628 
description  of  fungus,  620 
history,  619 
of  brain,  638 

of  bronchial  tubes  and  lungs,  626 
pathology  and  morbid  anatomy,  626 
prognosis,  642 
sources  of  infection,  625 
symptoms  and  diagnosis,  639 
treatment,  451 
Action  of  bacteria  on  tissues  of  body,  165 
Acute  glanders,  685 
suppuration,  244 
tetanus,  451 
Amputation  in  tuberculosis  of  joints,  589 
Anthrax,  659 

attenuation  of  virus,  666 

clinical  varieties,  668 

description  of  bacillus,  660 

differential  diagnosis,  674 

history,  659 

in  living  body  and  in  soil,  662 

infection  in  man,  664 

inoculation  experiments,  662 

intensification  of  virus,  666 

multiplication,  662 

osdema,  670 

of  external  surface,  669 

pathology  and  morbid  anatomy,  671 


Anthrax,  prognosis,  675 

prophylactic  inoculations,  66d 

pustule,  669 

treatment,  675 
Antiphlogistic  treatment  of  inflammation,  149 
Arterial  blood-supply,  defective,  194 
Arteries,  ligation  of,  194 
Arthrectomy,  in  tuberculosis  of  joints,  582 
Arthritis,  suppurative,  309 
Ascites,  tubercular,  544 
Asepsis,  23 

Aspiration  in  tuberculosis  of  joints,  581 
Atrophy,  81 

Attenuation  of  pathogenic  bacteria,  167 
Atypical  resection,  585 

Bacilli  of  putrefaction,  366 
Bacillus  coli  communis,  238 

of  anthrax,  description  of,  660 

multiplication  of,  662 
mallei,  679 

description  of,  680 

tenacity  of,  681 
pyocyaneus,  235 
pyogenes  foetidus,  366 
tetani,  437 

toxins  of,  444 
tuberculosis,  477 

cultivation,  482 

description,  479 

manner   of  infection  and   dissemination, 
529 

staining,  479 
Bacteria,  157 

action  of,  on  tissues  of  body,  165 
attenuation,  167 
classification,  157 
cultivation,  162 
death-point,  161 
elimination,  181 
fission,  159 
growth,  164 
immunity,  170 

inoculation  experiments,  167 
localization,  173 
multiplication,  159 
outside  of  the  body,  170 
■presence  of,  in  healthy  body,  171 
putrefactive,  192 

secondary,  or  mixed,  infection,  178 
specific,  189 
spores,  160 

therapeutic  inoculation,  169 
transmission  of,  from  parents  to  foetus,  182 
Bacteriological  causes  of  suppuration,  220 
Bladder,  tuberculosis  of,  612 
prognosis  and  treatment,  614 
symptoms  and  diagnosis,  613 


(693) 


694 


INDEX. 


Blastomycetic  dermatitis,  645 
diagnosis,  656 
fungus  of,  648 

inoculation  experiments,  651 
pathological  anatomy  and  histology,  653 
prognosis,  658 
treatment,  658 
Blood-corpuscles,  red,  96 

white,  94 
Blood-plates,  97 

Blood-vessels,  regeneration  of,  42 
Blue  pus,  243 
Bone  ferrule,  63 

regeneration  of,  54 
splint,  63 
suture,  63 
tuberculosis,  550 
artificial,  551 
clinical    and    bacteriological    researches, 

552 
means  of  differential  diagnosis,  562 
pathology  and  morbid  anatomy,  554 
prognosis,  564 

symptoms  and  diagnosis,  560 
treatment,  565 
Brain  abscess,  323 

actinomycosis  of,  638 
exploration  of,  330 
Bronchial  tubes  and  lungs,  actinomycosis  of, 
626 

Callus,  54 

Capillary  vessels,  93 
Cancer  aquaticus,  210 
Carbuncle,  265 

diagnosis,  266 

treatment,  267 
Cartilage,  33,  133 
Catarrhal  inflammation,  128 
Caustics  producing  necrosis,  197 
Cauterization  of  wound  in  hydrophobia,  470 
Cell-division,  13 

Central  nervous  system,  regeneration  of,  67 
Chemical  pyogenic  substances,  223 
Chromatin,  8 

five  phases  of,  9 
Chronic  circumscribed  suppurative  osteomye- 
litis, 305 
pathological  anatomy,  307 
symptoms,  306 
treatment,  307 

glanders,  685 

inflammation,  140 

suppuration,  245 

tetanus,  452 
Cicatrization,  19 
Classification  of  bacteria,  157 
Clinical  forms  of  erysipelas,  425 

septicaemia,  363 

suppuration,  244 

surgical  tuberculosis,  506 
Cloudy  swelling,  83 
Coagulation-necrosis,  205 


Cold  producing  necrosis,  196 

Color  in  gangrene,  201 

Condition  of  tissue  in  necrosis,  201 

Connective  tissue,  regeneration  of,  42 

Cornea,  inflammation  of,  130 

regeneration  of,  31 
Corpuscle,  third,  96 
Croupous  inflammation,  129 
Cultivation  of  bacteria,  162 

Decubitus,  194 

Defective  arterial  blood-supply,  194 

Degeneration,  81 

amyloid,  88 

colloid,  86 

fatty,  84 

mucoid,  86 

waxy,  86  .^ 

Dermatitis,  blastomycetic,  645 
Diabetic  gangrene,  210 
Diapedesis,  115,  210 
Diphtheritic  inflammation,  130 
Direct  causes  of  suppuration,  222 

transmission  of  bacteria,  182 

union  of  wounds,  3 
Disturbance  of  function  in  inflammation,  118 
Division  of  cells,  13 
Dry  gangrene,  208 

Elimination  of  gangrenous  part,  203 

pathogenic  bacteria,  181 
Elongation  of  tendon,  53 
Embolism,  395 

Emigration  of  leucocytes,  95 
Emphysema  in  gangrenous  tissue,  200,  207 
Empyema,  332 

after-treatment,  337 
multiple  resection  of  ribs,  337 
thoracoplastic  operation,  338 
bacteriological  studies,  332 
diagnosis,  333 
prognosis,  334 
treatment,  334 
drainage,  336 

evacuation  of  pus  and  removal  of  mem- 
branes, 336 
incisions,  335 
irrigation,  336 
resection  of  rib,  335 
Encapsulation  of  necrosed  tissue,  203 
Endocranial  suppuration,  315 
Epidermization,  22 

Epididymis  and  testicle,  tuberculosis  of,  608 
symptoms  and  diagnosis,  610 
treatment,  610 
Epiphyseolysis,  282 
Epithelia,  36 
Epithelioid  cells,  497 
Ergot  as  a  cause  of  gangrene,  197 
Ergotin  as  a  cause  of  gangrene,  214 
Erysipelas,  411 
bullosum,  426 
clinical  forms,  425 


INDEX. 


695 


Erysipelas,   description  of  streptococcus   ery- 
sipelatosus,  413 

erythematosum,  426 

facialis,  428 

gangrsenosum,  427 

history  of  microbic  origin,  411 

inoculation  experiments,  414 
for  therapeutic  purposes,  415 

manner  of  infection,  416 

metastaticum,  427 

migrans,  428 

phlegmonous,  426 

prognosis,  429 

relation  of,  to  puerperal  fever,  419 
phlegmonous  inflammation  and  suppura- 
tion, 420 

symptoms  and  diagnosis,  423 

traumatic,  429 

treatment,  430 
Erysipeloid,  433 

Essential  condition  for  growth  of  bacteria,  164 
Excision  of  wound  in  hydrophobia,  469 
Experiments,  inoculation,  of  bacteria,  167 
Exploration  of  brain,  330 

lung,  330 
External  parts,  gangrene  of,  198 
Exudation,  inflammatory,  110 

Fallopian  tubes,  tuberculosis  of,  605 

symptoms  and  diagnosis,  607 

treatment,  607 
False  joints,  causes  of,  59 
Farcy,  acute,  685 

chronic,  685 
Fascia  tuberculosis,  597 
Fermentation  fever,  363 

symptoms  and  diagnosis,  364 
Fibrous  tubercle,  501 
Fission  of  bacteria,  159 
Fistula,  273 
Fixed  tissue-cells,  98 
Folliculitis,  suppurative,  264 
Foot,  perforating  ulcer  of,  214 
Fragmentation  of  nucleus,  12 
Furuncle,  264 

Gangrene  caused  by  ergot,  197 

color  in,  201 

diabetic,  210 

dry,  208 

elimination,  203 

hospital,  212 

line  of  demarcation,  202 

moist,  208 

of  external  parts,  198 

prognosis,  214 

progressive,  207 

senile,  208 

swelling,  200 

symmetrical,  197 

treatment,  215 
Gangrenous  tissue,  emphysema  in,  200 
Genito-urinary  organs,  tuberculosis  of,  604 


Giant  cells,  495 
Glanders,  679 

acute,  685 

bacteriological  history,  679 

chronic,  685 

in  man,  6s6 

in  the  horse,  685 

inoculation  experiments,  682 

pathology  and  morbid  anatomy,  690 

prognosis,  691 

symptoms  and  diagnosis,  687 

treatment,  691 
Glands,  65 

kidney,  65 

liver,  65 

lymphatic,  66 

spleen,  65 

testicle,  65 
Glans  penis  and  urethra,  tuberculosis  of,  6' 
Gonococcus,  237 
Granulating  surfaces,  skin-grafting  in,  38 

wounds,  suturing  of,  29 
Granulation-tissue,  13 

vascularization  of,  16 
Granulomata,  141 
Growth  of  bacteria,  164 

Hemorrhagic  inflammation,  122 

Haemostasis,  25 

Head  tetanus,  452 

Healing  of  wounds,  2 

Heat  as  a  cause  of  necrosis,  196 

symptom  of  inflammation,  118 
Histogenesis  of  suppuration,  220 

tubercle,  492 
Histological  structure  of  tubercle,  490 
Histology  of  tubercle,  490 
Histozym,  364 
Hospital  gangrene,  212 
Hyaline  tubercle,  502 
Hydrophobia,  459 

a  microbic  disease,  461 

causes,  463 

in  the  dog,  460 

pathology  and  morbid  anatomy,  467 

prognosis,  466 

symptoms  and  diagnosis,  464 

treatment,  469 
cauterization  of  wound,  470 
excision  of  wound,  469 
palliative,  474 
prophylactic,  469 
inoculations,  470 

Icterus,  hematogenous,  401 

Immediate,  or  direct,  union  of  wounds,  3 

Immunity,  139 

Incubation  period  of  tetanus,  446 

Indirect  causes  of  suppuration,  222 

Infection-atrium  of  bacillus  tetani,  447 

Inflammation,  91 

catarrhal,  128 

chronic,  140 


696 


INDEX. 


Inflammation,  croupous,  129 
diphtheritic,  130 
emigration  of  leucocytes,  111 
hsemorrhagic,  122 
histological  elements  in,  92 
interstitial,,  122 
modification  of,  120 
of  mucous  membranes,  127 
of  non-vascular  tissue,  130 
of  serous  membranes,  123 
parenchymatous,  120 
phlegmonous,  420 
prognosis,  144 
suppurative,  123,  128 
symptoms,  100 

symptoms  and  diagnosis,  143 
treatment,  146 

anodynes,  155 

antiphlogistic,  149 

antipyretics,  153 

antiseptic  fomentations,  152 

application  of  cold,  151 

counter-irritation,  155 

diet,  154 

elevation  of  inflamed  parts,  150 

ignipuncture,  156 

massage,  155 

parenchymatous  injections,  147 

physiological  rest,  150 

stimulants,  154 

tonics  and  alteratives,  154 
Inflammatory  exudation,  110 

transudation,  117 
Inoculation  experiments  of  bacteria,  167 

tuberculosis  in  man,  485 
Inoculations,  prophylactic,  456 
Internal  necrosis,  197 

organs,  abscess  of,  309 
Intestinal  sepsis,  382 
Iris,  tuberculosis  of,  519 

Joints,  tuberculosis  of,  569 
etiology,  570 

pathology  and  morbid  anatomy,  571 
prognosis,  578 

symptoms  and  diagnosis,  574 
treatment,  579 

amputation,  589 

arthrectomy,  582 

aspiration,  581 

atypical  resection,  585 

rest,  580 

tapping  and  iodoformization,  581 

typical  resection,  588 
varieties  of,  572 

Karyokinesis,  8 
Karyolysis,  198 
Karyomytosis,  8 
Karyorhexis,  198,  206 

Large  cavities,  suppuration  in,  309 
Leptomeningitis,  suppurative,  319 


Leucocyte,  94,  495 

emigration  of,  95 
Ligation  of  arteries  in  their  continuity  causing 

gangrene,  194 
Liquefaction  of  necrosed  tissues,  203 
Localization  of  bacteria,  173 
Loss  of  function  in  osteomyelitis,  283 
Lung  abscess,  338 
Lupus,  tubercular  nature  of,  338 
Lymphatic  glands,  tuberculosis  of,  529 

pathological    histology    and   morbid   anat- 
omy, 531 

prognosis,  536 

symptoms  and  diagnosis,  533 

treatment,  536 
Lyssa  nervosa  falsa,  466 

/ 

Macrocytes,  495 

Malignant  oedema,  360 

Mammary  gland,  tuberculosis  of,  603 

Mastzellen,  56 

Metastatic  suppuration,  401 

Microbe  en  chapelet,  384 

Microbic  cause  of  tetanus,  447 

origin  of  erysipelas,  411 
suppuration,  220 
tuberculosis,  475 
Micrococcus  gonorrhceffi,  237 

pyogenes  tenuis,  232 
Modification  of  inflammation,  120 
Moist  gangrene,  208 
Mouth  and  tongue,  tuberculosis  of,  598 

pathology,  598 

symptoms  and  diagnosis,  599 

treatment,  600 
Mucous  membrane.  Inflammation  of,  127 

suppurative  inflammation  of,  247 

transplantation  of,  41 
Mummiflcation,  202 
Muscles,  regeneration  of,  47 
non-striated,  47 
striated,  48 

suture  of,  50 

tuberculosis  of,  596 
Myeloplaques,  57,  496 

Necrobiosis,  207 

Necrosed  tissue,  liquefaction  of,  203 

Necrosis,  187 

coagulation,  205 

encapsulation,  203 

etiology,  187 

general  symptoms,  203 

internal,  197 

pathological  and  clinical  varieties,  205 

prognosis,  214 

symptoms,  198 

treatment,  215 
Nerves,  peripheral,  regeneration  of,  69 
Nerve-suture,  74 

primary,  75 

secondary,  76 
Nervous  system,  central,  regeneration  cf,  67 


INDEX. 


697 


Noma,  210 

Non-vascular  tissue,  inflammation  of,  130 
regeneration  of,  31 

cartilage,  33 

cornea,  31 
Nucleus,  fragmentation  of,  12 

Obstructed  venous  circulation,  195 
Odor  of  necrosed  tissue,  202 
CEdema,  malignant,  360 
Opening  of  the  skull,  329 
Operation,  thoraeoplastic,  338 
Origin  of  suppuration,  220 
Osseous  tuberculosis,  cause  of,  550 
Osteoclasts,  57 
Osteomyelitis,  suppurative,  274 

early  operations,  295 

intermediate  operations,  296 

late  operations,  297 

Pachymeningitis,  suppurative,  315 
Pain  a  symptom  of  inflammation,  100 

necrosis,  198 

osteomyelitis,  200 
Parenchymatous  inflammation,  120 
Paronychia,  262 
Perforating  ulcer  of  foot,  214 

stomach  and  duodenum,  213 
Pericarditis,  suppurative,  340 
Pericardium,  incision  and  drainage,  341 

puncture  and  aspiration,  341 
Peritoneum,  tuberculosis  of,  541 

bacteriological  remarks,  541 

clinical  studies,  542 

pathology  and  morbid  anatomy,  543 

symptoms  and  diagnosis,  545 

treatment,  546 
Peritonitis,  adhesive,  545 

fibrinoplastic,  544 

suppurative,  342 
Phagocytosis,  134 
Phlegmonous  erysipelas,  426 

inflammation  with  suppuration,  256 
Physiological  rest,  27,  150 
Plasma-cells,  99 

-rhexis,  207 
Platycytosis,  134 
Progressive  gangrene,  207 

with  emphysema,  207 
Prophylactic  inoculations,  in  hydrophobia,  470 
Proteus  mirabills,  367 

vulgaris,  367 

Zenkeri,  368 
Ptomaines,  165,  368 

Puerperal  fever,  relation  of  erysipelas  to,  419 
Pulse,  after  ligation  of  artery,  199 
Purulent  infiltration,  progressive,  259 
Pus,  240 

blue,  243 

-corpuscles,  240 

description  and  specific  action  of  microbes 
of,  230 

red,  243 


Pus-serum,  240 

Putrefactive  bacteria,  192,  366 

Pyaemia,  383 

bacteriological       and       experimental      re- 
searches, 384 

etiology,  388 

in  rabbits,  385 

pathological  anatomy,  404 

prognosis,  404 

symptoms  and  diagnosis,  400 

treatment,  406 
Pyogenic  microbes  as  a  cause  of  sepsis,  362 

substances,  chemical,  223 

Ray-fungus,  620 

Raynaud's  disease,  197 

Red  pus,  243 

Redness  a  symptom  of  inflammation,  101 

osteomyelitis,  281 
Regeneration,  1 

of  different  tissues,  31 
Rest,  physiological,  27 
Reticulum,  tubercle,  498 
Rib,  resection  of,  in  empyema,  335 
Ribs,  multiple  resection  of,  337 

Saprffimia,  365 

prognosis,  373 

symptoms  and  diagnosis,  372 

treatment,  374 
Senile  gangrene,  208 
Senkungsabscess,  512 
Sepsis,  intestinal,  382 

pyogenic  microbes  as  a  cause  of,  362 
Septicaemia,  354 

bacteriological  researches,  354 

clinical  forms,  363 

in  mice,  354 

in  rabbits,  357 

progressive,  375 
causes,  376 

pathology  and  morbid  anatomy,  380 
prognosis,  379 

symptoms  and  diagnosis,  377 
treatment,  380 
Septopyasmia,  409 

kryptogenetic,  409 

spontaneous,  409 
Serous  membranes,  inflammation  of,  123 
Skin,  tuberculosis  of,  520 

pathology  and  morbid  anatomy,  523 

prognosis,  526 

symptoms  and  diagnosis,  524 

treatment,  527 
Skin-grafting,  38 
Skin-transplantation,  38 

Hirschberg's  method,  41 

Reverdin's  method,  38 

Wolfe's  method,  411 
Skull,  opening  of,  329 
Specific  bacteria,  189 
Spores  of  bacteria,  160 
Staphylococcus  cereus  albus,  231 


698 


INDEX. 


Staphylococcus  cereus  flavus,  232 
epidermidis  albus,  232 
flavescens,  232 
pyogenes  albus,  231 

citreus,  23i 
Stomach  and  duodenum,  perforatins  ulcer  of, 

213 
Strahlenpilz,  Bid 
Streptococcus  erysipelatosus,  413 

pyogenes,  234 
Suppuration,  220 
acute,  244 

bacterial  causes  and  histogenesis  of,  220 
chronic,  i45 
clinical  forms,  244 
direct  causes,  222 
endocranial,  315 

history  of  microbic  origin  of,  220 
in  large  cavities,  309 
in  wounds,  246 
indirect  causes,  222 
metastatic,  401 
relation  of  erysipelas  to,  420 
subacute,  245 
Suppurative  arthritis,  309 

bacteriological  researches,  309 

symptoms  and  diagnosis,  312 

treatment,  313 
inflammation,  123,  128 

of  mucous  membrane,  247 
leptomeningitis,  319 

symptoms  and  diagnosis,  321 

treatment,  322 
osteomyelitis,  274 

bacteriological  and  experimental  investi- 
gations, 275 

causes,  278 

chronic  circumscribed,  305 

diagnosis,  283 

history  of,  274 

pathological  anatomy,  287 

prognosis,  285 

symptoms,  279 

treatment,  290 
pachymeningitis,  315 

symptoms  and  diagnosis,  316 

treatment,  317 
pericarditis,  340 
peritonitis,  342 

bacteriological      and     experimental     re- 
searches, 342 

causes,  346 

clinical  and  bacteriological  studies,  345 

symptoms  and  diagnosis,  349 

treatment,  350 
tendo-vaginitis,  261 
Surface  epithelia,  36 
Surgical  tuberculosis,  475 

clinical  forms,  506 
Suture  of  bone,  63 
muscles,  50 
nerves,  74 
tendons,  51 


Suturing,  26 

of  granulating  wounds,  29 
Swelling  a  symptom  of  inflammation,  109 

osteomyelitis,  281 
Symmetrical  gangrene,  197 
Symptoms  of  inflammation,  100,  143 
Synovitis,  281,  572 

Temperature  in  gangrene,  199 

Tenderness  a  symptom  of  osteomyelitis,  200 

necrosis,  199 
Tendon-sheaths,  tuberculosis  of,  591 

pathology,  591 

prognosis,  593 

symptoms  and  diagnosiSr  593 

treatment,  593 
Tendoplasty,  52 
Tenorrhaphy,  51 
Tetanus,  436 

acute,  451 

antitoxin,  455 

bacillus,  437 

bacteriological  studies,  436 

chronic,  45:^ 

clinical  forms,  451 

cultivation,  437 

etiology,  446 

hydrophobicus,  452 

Infection-atrium,  447 

inoculation  experiments,  439 

neonatorum,  452 

pathology  and  morbid  anatomy,  453 

period  of  incubation,  446 

prognosis,  452 

specific  microbic  cause,  449 

symptoms  and  diagnosis,  449 

toxins  of  the  bacillus,  444 

treatment,  454 
Therapeutic  inoculation  of  bacteria,  169 
Third  corpuscle,  96 
Thoracoplastic  operation,  338 
Thrombosis,  390 
Tissue,  condition  of,  in  necrosis,  201 

connective,  42 

granulation,  13 

non-vascular,  31 

vascular,  35 
Tissue-cells,  fixed,  98 
Tissues,  action  of  bacteria  on,  165 

regeneration  of,  1 
Toxins  and  ptomaines,  165 

of  bacillus  tetani,  444 
Transmission  of  bacteria,  182 
Transplantation  of  mucous  membrane,  41 

skin,  38 
Transudation,  inflammatory,  117 
Trauma,  193 

Traumatic  erysipelas,  429 
Treatment  of  acute  abscess,  253 

anthrax,  675 

brain  abscess,  325 

carbuncle,  267 

chronic  abscess,  255 


IISTDEX. 


699 


Treatment  of  empyema,  334 
erysipelas,  430 
furuncle,  265 
gangrene,  215 
glanders,  691 
hydrophobia,  469 
inflammation,  146 
necrosis,  215 
paronychia,  263 

phlegmonous  inflammation,  257 
purulent  infiltration,  260 
pyEemia,  406 
sapra;mia,  374 
septicemia,  380 
suppurating  wounds,  28 
suppurative  arthritis,  313 

leptomeningitis,  322 

osteomyelitis,  290 

pachymeningitis,  317 

peritonitis,  350 

tendo-vaginitis,  261 
tetanus,  454 
tubercular  abscess,  513 

tendo-vaginitis,  593 
tuberculosis  of  bladder,  615 

bone,  565 

epididymis  and  testicle^  610 

Fallopian  tubes,  607 

joints,  579 

lymphatic  glands,  536 

mammary  gland,  603 

mouth  and  tongue,  600 

peritoneum,  546 

skin,  527 

tendon-sheaths,  593 

vulva,  vagina,  and  uterus,  605 
wounds,  23 

skin-grafting  In    38 
Trismus,  452 
Tubercle,  fibrous,  501 
hyaline,  502 

nodule,  arrangement  of  cells  in,  499 
growth  of,  500 
reticulated,  501 
reticulum,  498 
Tubercular  abscess,  509 
ascites,  544 
tendo-vaginitis,  591 

pathology,  591 

prognosis,  593 

symptoms  and  diagnosis  of,  593 

treatment,  593 
Tuberculosis  of  bladder,  612 
bones,  550 

epididymis  and  testicle,  608 
Fallopian  tubes,  605 
fascia,  597 

genito-urinary  organs,  604 
glans  penis  and  urethra,  608 
joints,  569 
intestine,  601 


Tuberculosis  of  kidney,  617 
lymphatic  glands,  529 
mammary  gland,  603 
mouth  and  tongue,  598 
muscles,  596 
peritoneum,  541 
tendon-sheaths,  590 
the  iris,  519 

skin,  520 

stomach,  601 

vascular  system,  618 

vesiculcB  seminales,  611 

vulva,  vagina,  and  uterus,  604 
Tuberculosis,  surgical,  475 
calcification,  505 
caseation,  502 
description  of  bacillus,  479 
growth  of  tubercle-nodules,  500 
hereditary  and  acquired  disposition,  506 
histogenesis  of  tubercle,  492 
histological  structure  of  tubercle,  494 
histology  of  tubercle,  490 
■  history  of  microbic  origin,  475 
inoculation  experiments,  482 

in  man,  485 
pathological  varieties,  501 

Ulcer,  269 

diagnosis,  271 

of  foot,  214 

of  stomach  and  duodenum,  213 

treatment,  272 
Ulceration  and  fistula,  269 
Union  of  wounds  by  primary  intention,  6,  23 

by  secondary  intention,  27 

immediate  or  direct,  3 


Varieties  of  tuberculosis  of  joints,  572 
Vascular  tissue,  regeneration  of,  35 

surface  epithelia,  36 
Vascularization  of  granulation-tissue,  16 
Venous  circulation,  obstructed,  195 
Vesiculse  seminales,  tuberculosis  of,  611 
Vessels,  capillary,  93 
Vulva,  vagina,  and  uterus,  tuberculosis  of,  604 


Wound,  cauterization  of,  in  hydrophobia,  470 
excision  of,  469 
healing  of,  2 

immediate  or  direct  union  of,  3 
of  blood-vessels,  regeneration  of,  42 
skin-grafting  in,  38 
suppuration  in,  246 
suturing  of  granulating,  29 
treatment  of,  23 

absolute  asepsis  in,  23,  28 
treatment  of  suppurating,  28 
union  by  primary  intention,  6,  23 
secondary  intention,  27 


RD31 


benn 


Se5 
1901 


